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

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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Correct Answer is C

Explanation

Choice A rationale:

Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.

Choice B rationale:

Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.

Choice C rationale:

Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.

Choice D rationale:

Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.

A. Respiratory rate. B. Oxygen saturation level. C. Heart rate. D. Chronic health condition. E. Current level of consciousness. F. Tremors

Correct Answer is ["A","B","C"]

Explanation

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is obtaining an oxygen saturation on a client.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","C"]

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.)