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
Choice A rationale:
A client who has an infection refusing an evening meal does not necessarily require an incident report. It may be due to factors such as loss of appetite or discomfort related to the infection, and nursing interventions like monitoring and reassessment should be prioritized.
Choice B rationale:
Writing an incident report is appropriate when a client falls when ambulating to the bathroom alone. Falls can lead to injuries and may indicate a need for a change in the client's care plan or additional safety measures. Reporting falls is essential for quality improvement and preventing future incidents.
Choice C rationale:
Recording an approximate amount of urine after it leaked from the client's catheter bag is an event that should be documented in an incident report. This helps in identifying potential issues with catheter care or equipment and ensures that proper corrective actions are taken.
Choice D rationale:
Administering the first dose of an antibiotic 1 hour before the collection of blood for culture and sensitivity testing is not necessarily an incident that requires reporting. While it may not be ideal timing, it may not have a significant impact on the accuracy of the test results. However, it's essential to follow facility policies and procedures regarding medication administration and specimen collection.
Choice E rationale:
Administering a daily medication at 1000 instead of the scheduled 0900 time is a medication error and should be reported in an incident report. Medication errors can have serious consequences, and reporting them is essential for proper documentation, investigation, and prevention of future errors.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Monitoring for muscle paralysis is crucial in botulism poisoning because it is a characteristic symptom of the condition. Botulinum toxin causes muscle weakness and paralysis, which can lead to respiratory distress. Monitoring for these symptoms allows for timely intervention.
Choice B rationale:
Placing the client in contact isolation is not a priority in botulism poisoning. Botulism is not typically transmitted from person to person, so isolation is not necessary. The focus should be on monitoring and supportive care.
Choice C rationale:
Checking for increased salivation is important because excessive salivation is a symptom of botulism poisoning. However, monitoring for muscle paralysis is more critical as it can lead to respiratory compromise.
Choice D rationale:
Administering clindamycin hydrochloride is not a standard treatment for botulism poisoning. The primary treatment involves supportive care and, in some cases, the administration of antitoxin if available.
Correct Answer is B
Explanation
Choice A rationale:
Evaluating the client for signs of infection is an important nursing action in post-procedure care, but it is not the priority immediately following an amniotomy. The primary concern after an amniotomy is fetal well-being, so monitoring the fetal heart rate is the priority.
Choice B rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. Amniotomy involves breaking the amniotic sac, which can potentially lead to changes in the fetal heart rate. Monitoring the fetal heart rate helps assess the baby's well-being and detects any signs of fetal distress.
Choice C rationale:
Observing the color and consistency of amniotic fluid is important for assessing the fluid for signs of meconium staining or infection, but it is not the immediate priority after an amniotomy. Checking the fetal heart rate takes precedence.
Choice D rationale:
Taking the client's temperature is an important part of assessing for infection or fever, but it is not the immediate priority following an amniotomy. Fetal well-being and monitoring are the primary concerns in the immediate post-amniotomy period.
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