A nurse is teaching a newly licensed nurse about incident reports.
The nurse should include that which of the following events requires an incident report?
An IV medication is administered via an oral route.
A client vomits their morning medications.
A lipid-lowering medication is administered to a client 1 hr after the scheduled time.
A client has an allergic reaction to an antibiotic.
The Correct Answer is A
Choice A rationale:
Administering IV medication via an oral route is a medication error and should be reported.
Choice B rationale:
A client vomiting their morning medications is an adverse event, but not all adverse events require an incident report. The nurse should assess the situation and report if it poses a risk to the patient's health.
Choice C rationale:
Administering a lipid-lowering medication to a client one hour after the scheduled time is a medication error, but again, the need for an incident report depends on the potential harm to the patient. In some cases, reporting this incident may be necessary.
Choice D rationale
An allergic reaction can occur in clients with no known drug allergies. Unless a drug was given in known allergies, it does not require an incident report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Keeping the feet together when lifting an object is not a proper body mechanics technique. It can lead to instability and an increased risk of injury because the base of support is not wide enough. Therefore, this choice does not indicate an understanding of body mechanics.
Choice B rationale:
Bending at the hip when lifting is also an incorrect body mechanics technique. Proper body mechanics involve bending at the knees and keeping the back straight to reduce the risk of back injuries. Bending at the hips can strain the lower back, making it an incorrect choice.
Choice C rationale:
Twisting the spine when lifting is a harmful practice in body mechanics. Twisting the spine can lead to spinal injuries, especially when lifting heavy objects. Proper body mechanics emphasize keeping the spine aligned and not twisting during lifting. Therefore, this choice does not indicate an understanding of body mechanics.
Choice D rationale:
Standing close to the object being moved is the correct body mechanics technique. This choice demonstrates an understanding of proper body mechanics because it reduces the strain on the back and minimizes the effort required to lift a heavy object. Keeping a wide base of support and using the leg muscles rather than the back muscles are essential principles of proper body mechanics. This is the correct choice. .
Correct Answer is D
Explanation
Choice A rationale:
Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.
Choice B rationale:
Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.
Choice C rationale:
Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .
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