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.
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 D
Explanation
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
Correct Answer is B
Explanation
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.
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