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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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should identify that the client is at risk of developing heart failure and may require further assessment and intervention.

Heart failure is suggested by the progressive decline in vital signs and laboratory results, such as increasing BUN and creatinine levels, which indicate worsening kidney function and can contribute to heart failure. The client’s fatigue, weakness, bilateral edema, and crackles in the lungs are clinical signs consistent with heart failure. The dry, flaky skin and coarse, thinning hair also reflect systemic issues that could be associated with heart failure and poor nutritional status.

The nurse should focus on further assessment to evaluate the severity of heart failure and intervention to manage symptoms, potentially including medication adjustments, fluid management, and additional diagnostic testing. These steps are crucial to addressing the client’s deteriorating condition and preventing further complications.

A. "The headaches should decrease as you get used to the medication." B. "Swallow the tablet whole to minimize your headaches." C. "You should take the medication on an empty stomach to prevent a headache." D. "You can discontinue the medication until the headache goes away."

Correct Answer is A

Explanation

A. Correct. Isosorbide dinitrate is a medication used to prevent angina. Headaches are a common side effect when starting the medication, but they often decrease over time as the body adjusts.
B. Incorrect. Swallowing the tablet whole will not necessarily minimize headaches associated with isosorbide dinitrate.
C. Incorrect. Taking the medication on an empty stomach is not typically necessary to prevent headaches.
D. Incorrect. Discontinuing the medication without consulting a healthcare provider is not recommended, as abrupt discontinuation could lead to worsening of symptoms.

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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 assisting with the care of a client in an outpatient provider's office. Exhibits The nurse should identify that the client is at risk of developing dropdown and may require further dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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