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 B

Explanation

A. Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B. Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C. Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D. Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.

A. Cottage cheese B. Puffed rice cereal C. Tomato juice D. Bran muffin

Correct Answer is D

Explanation

A. Cottage cheese is a dairy product that is not particularly high in fiber and might not effectively help with constipation.
B. Puffed rice cereal is often low in fiber and might not be the best choice to address constipation.
C. While tomato juice can have some benefits, it is not a high-fiber choice to help alleviate constipation.
D. Correct. Bran muffins are a good source of dietary fiber, which can help promote regular bowel movements and relieve constipation.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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