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 C

Explanation

Choice A rationale:

Enabling the airbag when the baby is in the front seat of the car is incorrect. Airbags can be dangerous for infants and young children, and it is recommended to keep them in the rear seat, preferably in a rear-facing car seat.

Choice B rationale:

Positioning the car seat's retainer clip at the level of the baby's belly button is incorrect. The retainer clip should be at armpit level to ensure proper positioning and safety.

Choice C rationale:

Keeping the baby rear-facing in the car seat until she is 2 years old is the correct understanding of car seat safety. This statement aligns with the American Academy of Pediatrics (AAP) recommendations, which suggest keeping infants rear-facing as long as possible, ideally until they reach the maximum height and weight limits of their car seat.

Choice D rationale:

Placing the baby in the car seat at a 90-degree angle is incorrect. The correct angle for a rear-facing car seat depends on the manufacturer's guidelines but typically ranges from 30 to 45 degrees. The 90-degree angle is not safe and can compromise the baby's airway.

A. Response to other clients B. Sleep patterns C. Hygiene patterns D. Interaction with the nurse

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.

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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 reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,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.)