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 D

Explanation

Choice A rationale:

Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.

Choice B rationale:

Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.

Choice C rationale:

Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.

Choice D rationale:

Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.

A. Instruct the client to take a brisk walk. B. Position the client on their left side. C. Check the client's temperature. D. Provide the client with a glass of orange juice.

Correct Answer is B

Explanation

Choice A rationale:

"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.

Choice B rationale:

"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.

Choice C rationale:

"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.

Choice D rationale:

"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

Correct Answer is D

Explanation

A nurse is collecting data from a client during a routine prenatal visit.The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.Which of the following actions should the nurse take?

Correct Answer is 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.)