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. 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.

A. "Take an antacid if the medication causes gastrointestinal upset." B. "Restrict your daily fluid intake while taking this medication." C. "This medication can increase your risk for sunburn." D. "Expect to experience diarrhea while taking this medication."

Correct Answer is C

Explanation

Ciprofloxacin is a fluoroquinolone antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. It is important for the client to be aware of this potential side effect and take appropriate precautions, such as using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure while taking the medication.

"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or mineral supplements containing calcium, magnesium, aluminum, or iron, as they can interfere with the absorption of the medication. If the client experiences gastrointestinal upset, they should consult their healthcare provider for appropriate management.

"Restrict your daily fluid intake while taking this medication." It is important for the client to maintain adequate hydration while taking ciprofloxacin, as it is important for the elimination of the medication from the body. Restricting fluid intake can lead to dehydration and may affect the effectiveness of the medication. The client should be encouraged to drink plenty of fluids unless otherwise instructed by their healthcare provider.

"Expect to experience diarrhea while taking this medication." While gastrointestinal side effects such as diarrhea can occur with ciprofloxacin, it is not appropriate to state that the client should expect to experience it. Diarrhea can be a sign of a serious adverse reaction, such as Clostridium difficile infection, and should be reported to the healthcare provider for further evaluation and management.

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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 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

A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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