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 A

Explanation

The correct answer is a. Plan to remove the restraints as soon as the client is calm.

Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.

Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.

Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.

Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.

A. A client who has cirrhosis and severe pruritus. B. A client who has a femur fracture and reports numbness of the toes. C. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge. D. A client who had a renal biopsy 3 hr ago and has pink-tinged urine.

Correct Answer is B

Explanation

Choice A rationale:

The client with cirrhosis and severe pruritus is experiencing discomfort, but it is not an immediate life-threatening situation. The priority should be given to clients with conditions that pose an immediate risk to life.

Choice B rationale:

Numbness of the toes in a client with a femur fracture can indicate compromised circulation or nerve damage. This is a critical situation that requires immediate assessment and intervention to prevent complications like compartment syndrome or permanent nerve damage.

Choice C rationale:

A client who had a laparoscopic appendectomy 8 hours ago and is awaiting discharge is likely stable. While they need monitoring, it is not an urgent priority compared to the client with a potential vascular or nerve issue.

Choice D rationale:

Pink-tinged urine after a renal biopsy could indicate some bleeding, but it is not as urgent as the situation of the client with a femur fracture and numbness of the toes.

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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

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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.)