A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

An approximate amount of urine was recorded after the urine leaked from the client's catheter bag.

A client received an 0900 daily medication at 1000.

A client who has an infection refused the evening meal.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing.

A client fell when ambulating to the bathroom alone.

Answer and Explanation

Correct Answer : A,B,E

The nurse should write an incident report for the following events:
1.   An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2.   A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3.   A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

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Correct Answer is ["A","C","D","F","G","H"]

Explanation

A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

A. Hyperglycemia B. Hand tremors C. Nausea D. Shortness of breath

Correct Answer is D

Explanation

A. Incorrect. Epinephrine is not used to treat hyperglycemia.
B. Incorrect. Epinephrine is not used to treat hand tremors.
C. Incorrect. Epinephrine is not used to treat nausea.
D. Correct. Epinephrine is used to treat severe allergic reactions, including anaphylaxis, which can involve manifestations such as shortness of breath, difficulty breathing, and wheezing.

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A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

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