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. Newborns' heads can be sensitive, and washing with a moist towelette might not be gentle enough for their delicate skin.
B. Correct. Newborns' skin is sensitive, and using a warm, wet washcloth without soap is recommended to gently clean their face.
C. Incorrect. Bathing a newborn under a running faucet can be challenging and might expose the baby to temperature variations. It's important to ensure that the baby is comfortable during bathing.
D. Incorrect. Newborns don't need to be bathed daily. Bathing them too frequently can dry out their skin and lead to discomfort.

A. Tell the client she should discuss this decision with her family. B. Support the client's decision to stop the treatment. C. Discuss alternative treatment methods with the client. D. Ask the facility chaplain to visit the client.

Correct Answer is B

Explanation

The correct answer is choiceb. Support the client’s decision to stop the treatment.

Choice A rationale:

While discussing the decision with family can be important, the nurse’s primary responsibility is to respect and support the client’s autonomy and decision-making capacity. Encouraging the client to discuss with family is secondary to supporting their decision.

Choice B rationale:

Supporting the client’s decision to stop treatment respects their autonomy and right to make decisions about their own care.This is a fundamental principle in nursing ethics and patient-centered care.

Choice C rationale:

Discussing alternative treatment methods may be appropriate in some contexts, but in this case, the client has already made a decision to stop dialysis. The nurse should focus on supporting this decision rather than suggesting alternatives.

Choice D rationale:

Asking the facility chaplain to visit the client can be supportive, but it should not be the nurse’s primary action. The nurse should first support the client’s decision and then offer additional support services as needed.

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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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