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.)

A client who has an infection refused the evening meal.

A client fell when ambulating to the bathroom alone.

An approximate amount of urine was recorded after the urine leaked from the client's catheter bag.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing.

A client received an 0900 daily medication at 1000.

Answer and Explanation

Correct Answer : B,C,D,E

The correct answers are Choices B, C, D, and E.

Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.

Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.

Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.

Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.

Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.

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Correct Answer is D

Explanation

Choice A rationale:

Replace the IV pump's tubing. Replacing the IV pump's tubing is not the appropriate action when the IV pump screen is malfunctioning. Malfunctioning tubing does not typically affect the pump's screen or settings.

Choice B rationale:

Clear the settings and reset the IV pump. Clearing the settings and resetting the IV pump may not be effective if the screen is malfunctioning. It is important to ensure the accuracy and safety of IV fluid administration, and troubleshooting the screen is not a reliable solution in the case of a malfunction.

Choice C rationale:

Plug the IV pump's cord into a different outlet. Changing the outlet may help if the issue is related to electrical power, but it is not the most appropriate action when the IV pump screen is malfunctioning. Safety concerns and potential equipment issues warrant discontinuing use and tagging the pump.

Choice D rationale:

Discontinue use and tag the IV pump. When the IV pump screen is malfunctioning, the safest and most appropriate action is to discontinue its use and tag the pump. This ensures that the malfunctioning equipment is not used on other patients and that a thorough inspection and repair can be conducted to prevent potential harm to the patient.

A. First-hand experience with wound care products B. A peer-reviewed journal article C. Information from a wound care product vendor D. An entry on a nursing blog addressing wound healing

Correct Answer is B

Explanation

Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.

First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.

Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.

An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.

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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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Naxlex Comprehensive Predictor Exams

A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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.)