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 D
The correct answer is Choice D.
Choice A rationale: Withdrawing consent is a client’s legal right. No error or unexpected event occurred, so no incident report is required.
Choice B rationale: Preference for shower timing is a routine care adjustment, not an adverse or unusual event requiring documentation.
Choice C rationale: Vomiting may be a side effect, but unless it causes harm or is unexpected, it doesn’t meet incident report criteria.
Choice D rationale: A medical emergency involving a visitor is unexpected and requires documentation for liability, safety, and institutional response tracking.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.
Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.
Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.
Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.
Correct Answer is A
Explanation
The charge nurse is demonstrating the right of supervision by checking with other nursing personnel on the unit throughout the day to determine if they are completing tasks. This means that the charge nurse is providing appropriate supervision and monitoring of the delegated tasks to ensure that they are being completed correctly and that the client's needs are being met.
Option B is incorrect because it refers to ensuring that the circumstances are appropriate for delegation.
Option C is incorrect because it refers to delegating tasks to the right person who has the appropriate skills and knowledge to complete them.
Option D is incorrect because it refers to clear communication between the delegator and delegatee about the task being delegated.
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