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. Understands that everyone dies eventually: Preschoolers typically do not have a concrete understanding of the concept of death or the inevitability of death for everyone. Their understanding is usually very limited and concrete, so this would not be consistent with their developmental stage.

B. Recognizes the parent will never wake up: Preschoolers may have difficulty understanding the permanence of death. They might think that the deceased parent will wake up eventually or return, as their grasp on the concept of permanence is not fully developed.

C. Expresses curiosity about the funeral service: While preschoolers may be curious about many things, including new experiences, their understanding of a funeral and its significance may be limited. They might not fully grasp the meaning behind the service but may ask questions out of curiosity.

D. Believes death is punishment for bad behavior: Preschoolers often think in magical or egocentric ways and may believe that death is a punishment for something they or others did wrong. This belief reflects their developmental stage, where they may not understand the abstract concept of death and may interpret it in relation to their own actions or behaviors.

A. Tingling of the scalp B. Voice alteration C. Neck pain D. Temporary memory loss

Correct Answer is D

Explanation

A. Incorrect. Tingling of the scalp is not a common adverse reaction following electroconvulsive therapy (ECT.
B. Incorrect. Voice alteration is not a common adverse reaction following ECT.
C. Incorrect. Neck pain is not a common adverse reaction following ECT.
D. Correct. Temporary memory loss is a common adverse reaction following ECT. Some clients may experience confusion and memory deficits immediately after the procedure, but these effects are typically temporary and resolve as the client recovers from the treatment.

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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

A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.

Correct Answer is D

Explanation

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