A nurse is using incident reports with a group of newly licensed nurses. The nurse should include in the discussion that which of the following situations requires completion of an incident report?

A nurse finds medication on the client’s bedside table upon entering the room.

A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500

A client's medication record MARI indicates the 0800 dose of morphine was withheld because the client refused to take the medication

A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the clients bedside

Answer and Explanation

The Correct Answer is B

Rationale:

A. A nurse finds medication on the client’s bedside table upon entering the room: While this is a safety concern, it may not necessarily require an incident report unless it resulted in harm or was due to a medication error. It should be documented and investigated, but may not meet the threshold for a formal report depending on facility policy.

B. A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500: This represents a medication administration error—giving the drug significantly earlier than prescribed. Administering time-sensitive medications outside the scheduled time can affect patient safety and should be reported using an incident report for evaluation and prevention.

C. A client's MAR indicates the 0800 dose of morphine was withheld because the client refused to take the medication: Client refusal of medication is not an error and does not require an incident report. It should be documented in the medical record along with any related assessments or follow-up, but it is not a reportable incident.

D. A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the client’s bedside: This situation suggests a delay in removing the IV bag, which is a minor deviation from ideal practice but typically does not require an incident report unless there was harm, contamination, or risk of adverse outcome.

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Correct Answer is B

Explanation

Rationale:

A. Ensure the client is aware of the scheduled time for the procedure: While knowing the time of surgery is helpful for preparation, it is not a requirement for informed consent. The key issue is whether the client understands the procedure itself and its implications.

B. Make sure the client has been informed about the risks of the procedure: Before witnessing informed consent, the nurse must confirm that the client has received complete information from the provider about the procedure, including its purpose, risks, benefits, and alternatives. This ensures the client is making an informed decision.

C. Ensure the client receives opioid medication prior to giving consent for the procedure: Administering opioids before consent can impair the client's cognitive ability to understand and voluntarily agree. Consent must be obtained while the client is alert and oriented, prior to any sedating medications.

D. Make sure the client's family agrees to the procedure: Consent is only valid when given by the competent client. Family agreement is not legally required unless the client is unable to consent and a legal surrogate is designated.

A. "Rest in supine position for 30 minutes after a meal." B. "Dress the affected side first C. "Use the arm on your affected side to brush your hair." D. "Use a straw when you drink liquids."

Correct Answer is B

Explanation

Rationale:

A. "Rest in supine position for 30 minutes after a meal.": Lying flat after a meal increases the risk of aspiration particularly in stroke clients who may have impaired swallowing. A more upright position should be encouraged during and after meals to reduce this risk.

B. "Dress the affected side first.": Dressing the affected side first promotes independence and makes the task easier by minimizing the need for fine motor coordination on the impaired side. It also reduces frustration and helps establish a safe, consistent dressing routine.

C. "Use the arm on your affected side to brush your hair.": Stroke often leads to muscle weakness or paralysis on one side, making it difficult or unsafe to perform tasks with the affected limb. Initially, clients should use their stronger arm while the affected side is supported and rehabilitated gradually.

D. "Use a straw when you drink liquids.": Using a straw can increase the risk of aspiration in clients with post-stroke dysphagia by promoting rapid fluid intake. It is generally contraindicated until a swallowing assessment confirms that it is safe.

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A nurse is using incident reports with a group of newly licensed nurses. The nurse should include in the discussion that which of the following situations requires completion of an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is scheduled for surgery. Which of the following steps should the nurse take prior to witnessing informed consent?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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