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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
Correct Answer is A
Explanation
Choice A rationale:
"Nervousness." Rationale: This is a correct instruction. Thyrotoxicosis is a condition characterized by excessive thyroid hormone production. Common symptoms include nervousness, anxiety, restlessness, and emotional instability. The client should notify the healthcare provider if they experience these symptoms as they may indicate an excessive dose of levothyroxine.
Choice B rationale:
"Cough." Rationale: Cough is not typically associated with thyrotoxicosis. Symptoms of thyrotoxicosis are primarily related to an overactive thyroid gland and may include palpitations, weight loss, heat intolerance, and nervousness.
Choice C rationale:
"Pruritus." Rationale: Pruritus (itching) is not a common symptom of thyrotoxicosis. Itchy skin is more likely related to other dermatological or systemic conditions and should be evaluated separately.
Choice D rationale:
"Polyuria." Rationale: Polyuria (excessive urination) can be associated with both hypothyroidism and hyperthyroidism, but it is not a typical manifestation of thyrotoxicosis. Increased urination is more commonly seen in conditions like diabetes mellitus. Therefore, polyuria alone may not be indicative of thyrotoxicosis in this context.
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