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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Calling the supervisor to ask for another nurse is not the first action the charge nurse should take when noticing the smell of alcohol on a nurse's breath. While it's important to involve the supervisor, immediate action to ensure patient safety is required.

Choice B rationale:

Documenting objective findings about the situation is a valid step in the process, but it should not be the first action. The charge nurse's primary responsibility is to address the immediate safety concerns.

Choice C rationale:

Removing the nurse from the client care area is the first action the charge nurse should take when smelling alcohol on a nurse's breath. This action ensures patient safety and prevents potential harm caused by impaired nursing care.

Choice D rationale:

Assigning clients to the remaining staff is not the first action to take when there is suspicion of alcohol impairment in a nurse. Patient safety and addressing the situation involving the impaired nurse take precedence.

A. Decreased skin turgor. B. Decreased blood pressure. C. Weight loss. D. Crackles heard in the lungs.

Correct Answer is D

Explanation

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Correct Answer is D

Explanation

A nurse is assisting a client who has cancer to select high-protein foods. Which of the following foods should the nurse recommend as the highest source of protein?

A nurse is caring for a 3-year-old child who has acute bacterial conjunctivitis of the right eye and has been prescribed bacitracin ophthalmic ointment. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has hyponatremia.Which of the following findings should the nurse expect?

A nurse is reinforcing discharge teaching to a client following arthroscopic (joint) surgery.To prevent postoperative complications which of the following actions should be reinforced during the teaching of Continuous passive motion (CPM)?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

A nurse is reinforcing teaching about laboratory testing with a client.Which of the following findings should the nurse include as an indicator of infection?

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus.Which of the following statements by the client indicates an understanding of the teaching?

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.)