A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?

Nitroglycerin transdermal was applied to a client’s chest.

Cefotaxime was administered to a client after obtaining blood cultures.

Digoxin was administered to a client who has a heart rate of 64/min.

Insulin lispro was administered to a client immediately before bed.

Answer and Explanation

The Correct Answer is D

Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.

Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.

Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.

Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.

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Correct Answer is A

Explanation

Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.

Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.

The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.

Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.

The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.

Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.

The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.

A. Place the client’s bed in the low position. B. Encourage the client to wear socks when ambulating. C. Position the client’s bedside table at the foot of the bed. D. Raise four side rails on the client’s bed.

Correct Answer is A

Explanation

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.

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A nurse is reinforcing teaching with a newly licensed nurse about incident reports. The nurse should identify that which of the following situations requires the completion of an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?