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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A laissez-faire leadership style is characterized by a lack of involvement or control, and it is not typically associated with perpetrators of child abuse.
Choice B rationale:
Self-blame for financial problems may lead to stress but is not a characteristic finding of perpetrators of child abuse.
Choice C rationale:
High self-esteem is not typically associated with perpetrators of child abuse. In fact, abusers often have low self-esteem and exert power and control over others to compensate for it.
Choice D rationale:
Perpetrators of child abuse often have rigid expectations of behavior from their children and may employ authoritarian parenting styles. This characteristic can contribute to abusive behaviors.
Correct Answer is A
Explanation
Choice B rationale:
Prothrombin time. Monitoring prothrombin time is not typically required for clients taking levothyroxine. Prothrombin time is a measure of blood clotting and is not directly affected by thyroid hormone replacement therapy.
Choice C rationale:
Blood urea nitrogen. Monitoring blood urea nitrogen is not specifically related to levothyroxine therapy. Blood urea nitrogen is a measure of kidney function and is not typically affected by thyroid hormone replacement.
Choice D rationale:
Serum potassium. Monitoring serum potassium levels is important for some medications, but it is not a primary concern when a client is taking levothyroxine. Levothyroxine is primarily used to replace or supplement thyroid hormones, and its main focus is on thyroid function.
Choice A rationale:
Triiodothyronine. Triiodothyronine (T3) is one of the thyroid hormones, and monitoring its levels is essential when a client is taking levothyroxine. Levothyroxine is a synthetic form of thyroxine (T4), which the body converts into triiodothyronine (T3) Monitoring T3 levels helps ensure that the client's thyroid hormone replacement therapy is effective and that they are not experiencing over- or under-dosage.
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