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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Severe immunodeficiency: The MMR vaccine is a live attenuated vaccine and is contraindicated in clients with severe immunodeficiency, such as those undergoing chemotherapy or with advanced HIV/AIDS. These individuals cannot mount an appropriate immune response, placing them at risk for vaccine-related complications.
B. Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.
C. Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.
D. Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.
Correct Answer is D
Explanation
Rationale:
A. Administer disulfiram: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is consumed. It has no therapeutic use in the treatment of gambling disorders and would not address the behavioral or psychological components involved.
B. Encourage participation in exposure therapy: Exposure therapy is typically used for anxiety disorders, such as phobias or post-traumatic stress disorder. It is not a standard treatment for gambling disorder, which requires cognitive and behavioral interventions tailored to impulse control.
C. Administer memantine: Memantine is primarily used to manage symptoms of Alzheimer’s disease and is not an approved or evidence-based treatment for gambling disorder. Its mechanism of action is unrelated to the neurobiology of behavioral addictions like gambling.
D. Recommend client join a self-help group: Self-help groups like Gamblers Anonymous provide peer support and structured recovery programs that address compulsive gambling behaviors. Participation can foster accountability, emotional support, and behavioral change, making this a relevant and effective nursing intervention.
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