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 A
Explanation
Choice A rationale:
The client who is unresponsive to verbal commands and changes position occasionally is at the highest risk for developing a pressure injury. Pressure injuries, also known as pressure ulcers or bedsores, are more likely to occur in clients who cannot independently reposition themselves. Unresponsive clients are unable to sense discomfort and adjust their positions, which makes them particularly vulnerable to pressure injuries. Changing position occasionally may not be sufficient to prevent these injuries in such clients. Pressure injuries are a result of prolonged pressure on a particular area, causing damage to the skin and underlying tissues due to reduced blood flow. Clients who are unresponsive need more vigilant monitoring and frequent repositioning to prevent pressure injuries.
Choice B rationale:
The client who is alert and responsive and eats 25% of each meal is not at the highest risk for developing a pressure injury. While this client may have some nutritional concerns, the primary risk factor for pressure injuries is immobility or the inability to change position independently. The ability to eat some of each meal indicates at least some level of mobility and participation in activities of daily living, which can help reduce the risk of pressure injuries.
Choice C rationale:
The client who is receiving enteral feeding and can change position independently is not at the highest risk for developing a pressure injury. Enteral feeding provides adequate nutrition, and the ability to change position independently reduces the risk of pressure injuries. Changing positions helps distribute pressure and prevents localized areas of prolonged pressure that can lead to tissue damage.
Choice D rationale:
The client who makes frequent slight changes in position and walks occasionally is also not at the highest risk for developing a pressure injury. Walking and frequent position changes help in preventing pressure injuries. The risk is lower for clients who can independently make slight changes in position and engage in ambulation. These activities promote blood flow and relieve pressure on specific areas of the body.
Correct Answer is C
Explanation
Choice A rationale:
Dysphagia is a difficulty or discomfort with swallowing and is not a complication of diverticulitis. Diverticulitis typically involves inflammation or infection of diverticula in the colon and may present with symptoms such as abdominal pain, fever, and changes in bowel habits, but dysphagia is not a characteristic feature.
Choice B rationale:
Ulcerative colitis is a distinct inflammatory bowel disease and is not a complication of diverticulitis. These conditions have different causes and affect different parts of the digestive tract. While both conditions can cause abdominal discomfort, they are not directly related.
Choice C rationale:
Peritonitis is a potential complication of diverticulitis. When diverticula become infected and rupture, they can spill their contents into the abdominal cavity, leading to peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity). This condition can be life-threatening and requires prompt medical intervention.
Choice D rationale:
Crohn's disease is a separate inflammatory bowel disease and is not a complication of diverticulitis. Crohn's disease can affect any part of the digestive tract, whereas diverticulitis typically occurs in the colon. They have distinct clinical features and treatment approaches. .
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