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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Maintaining abduction of the residual limb with a pillow is not relevant to promoting mobility and independence for a client with an above-the-knee amputation.
B. Correct. Encouraging the client to use the overbed trapeze can help the client perform upper body movements and reposition independently, which is essential for maintaining mobility.
C. Incorrect. Avoiding a prone position may not be necessary for the client after an above-the-knee amputation and does not directly contribute to mobility and independence.
D. Incorrect. Keeping a loose, absorbent dressing over the surgical site is important for wound care, but it does not directly promote mobility and independence.
Correct Answer is A
Explanation
A. Correct. Pancreatitis typically results in elevated serum lipase and amylase levels due to pancreatic inflammation.
B. Incorrect. Decreased albumin might be seen in conditions affecting liver function or malnutrition but is not specific to pancreatitis.
C. Incorrect. Elevated ammonia levels are often associated with liver dysfunction rather than pancreatitis.
D. Incorrect. Prolonged PT/INR are indicators of impaired clotting, usually associated with liver disease rather than pancreatitis.
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