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,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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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Delaying the discussion about managing hair loss when the client has expressed concern is not the best approach. The nurse should provide information and support when the client seeks it.
Choice B rationale:
Discouraging the client from worrying about hair loss at this moment is not empathetic. The client's concerns should be acknowledged and addressed.
Choice C rationale:
Expressing empathy and relating to the client's emotional experience is a good practice, but it does not directly answer the client's question about managing hair loss.
Choice D rationale:
Offering to get information about head-covering options indicates an understanding of the client's concerns and provides a proactive solution. It shows empathy and willingness to support the client during chemotherapy, where hair loss can be a significant emotional issue.
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.
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