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

Explanation

A. Correct. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.

B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.

C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.

D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

A. "I will wipe away yellow crusts that form around the incision." B. "I will apply pressure with gauze if I see bleeding." C. "I will make sure that my baby's diaper is applied snugly." D. "I will apply antibiotic ointment to my baby's penis."

Correct Answer is B

Explanation

A. Incorrect. Yellow crusts around the incision site are a normal part of healing after circumcision. Wiping them away can disrupt the healing process.

B. Correct. Applying pressure with gauze if bleeding occurs helps control bleeding and supports the healing process after circumcision.

C. Incorrect. A snug diaper might cause friction and discomfort for the healing circumcision site.

Diapers should be applied loosely to avoid rubbing against the area.

D. Incorrect. Applying antibiotic ointment is generally not recommended for circumcision care, especially after a Plausible circumcision. It can interfere with healing and increase the risk of infection.

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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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Correct Answer is A

Explanation

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Correct Answer is B

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