A nurse is reinforcing teaching with a group of newly licensed nurses about completing an incident report. For which of the following situations should the nurse complete an incident report?
A client decides not to have a colonoscopy after signing the consent form.
A client requests to take a shower in the evening rather than in the morning.
A client has an episode of vomiting after receiving medication for hypertension.
A client's family member becomes short of breath and reports having chest pain.
The Correct Answer is C
An incident report should be completed if a client has an episode of vomiting after receiving medication for hypertension. This is an unexpected event that may indicate an adverse reaction to the medication and requires documentation and follow-up.
Option A does not require an incident report as the client has the right to refuse treatment.
Option B also does not require an incident report as it is a routine request.
Option D may require immediate medical attention, but it does not necessarily require an incident report as it involves a family member rather than a client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
SBAR stands for Situation, Background, Assessment, and Recommendation. It is a systematic method of communication that provides a structured framework for conveying important information about a patient. To ensure that the report is thorough, the nurse needs to include information about the situation of the patient, the background leading up to the situation, an assessment of the patient, and recommendations for moving forward.
Option d is incorrect because barriers to providing treatment are not part of the SBAR framework.
Option f is incorrect because the reason why the report is needed is not part of the SBAR framework.
Correct Answer is D
Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as assisting with activities of daily living, hygiene, and nutrition, as well as those tasks that support professional nursing assessments ². Providing postmortem care for a client who has died [d] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP. Educating a client on the use of a blood glucose monitor [a] involves patient education, which is typically the responsibility of a licensed nurse.
Interpreting a client's vital signs [b] involves assessing the client's health status, which is also typically the responsibility of a licensed nurse. Performing a central line dressing change for a client [c] is a complex task that requires specialized knowledge and skills.
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