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 D

Explanation

A. The cause of death is typically determined and documented by the attending physician or coroner, not the nurse.
B.While this information might be included in other parts of the medical record prior to the death, it is not required in postmortem documentation.
C. The nurse should verify that advance directives were followed, but the actual copy of the advance directives does not need to be included in the postmortem documentation. These should already be part of the client’s medical record.
D. Documenting the location of the identification tag is important for proper identification of the body after death. This ensures that the body is correctly identified during transfer to the morgue or funeral home.

A. "Open the fireplace dampers in the day room." B. "Cover the electrical outlets with wet towels." C. "Move clients to a room above ground with few windows." D. "Turn on fans in the facility to circulate air."

Correct Answer is C

Explanation

A. Incorrect. Opening the fireplace dampers may allow external contaminants to enter the facility and is not recommended during an external chemical disaster.
B. Incorrect. Covering electrical outlets with wet towels may not provide effective protection against chemical contaminants and is not a recommended action.
C. Correct. Moving clients to a room above ground with few windows helps protect them from potential exposure to external chemical contaminants. Windows can allow contaminants to enter, and an aboveground location can reduce the risk of exposure.
D. Incorrect. Turning on fans may circulate contaminated air throughout the facility and is not recommended during a chemical disaster.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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