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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Prednisone can cause blood glucose levels to increase." Rationale: This statement is accurate. Prednisone is a corticosteroid medication known to cause hyperglycemia (high blood glucose levels) as a side effect. It is important for the nurse to monitor the client's blood glucose levels while they are taking prednisone, especially if the client has preexisting diabetes or risk factors for diabetes.
Choice B rationale:
"Older adults are at risk for developing type 1 diabetes mellitus." Rationale: This statement is incorrect. Type 1 diabetes mellitus typically develops in childhood or early adulthood and is characterized by autoimmune destruction of the insulin-producing cells in the pancreas. Older adults are more at risk for developing type 2 diabetes, which is different from type 1 diabetes in terms of its etiology and pathophysiology.
Choice C rationale:
"Having COPD causes blood glucose levels to fluctuate." Rationale: This statement is not accurate. COPD (Chronic Obstructive Pulmonary Disease) primarily affects the respiratory system and does not directly cause blood glucose level fluctuations. Blood glucose levels can be affected indirectly in some cases due to factors like medications or stress associated with the illness, but it is not a direct result of COPD.
Choice D rationale:
"Albuterol treatments can cause blood glucose levels to decrease." Rationale: This statement is not a typical effect of albuterol treatments. Albuterol is a bronchodilator commonly used to treat respiratory conditions like COPD and asthma. It is not known to cause significant decreases in blood glucose levels.
Correct Answer is ["A","B"]
Explanation
A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.
B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.
C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.
D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.
So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.
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