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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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

A.Provide the caregiver with information on behavior therapy: Behavior therapy is a first-line, evidence-based nonpharmacologic intervention for ADHD, particularly in children. Educating caregivers about behavioral strategies helps improve symptom management and supports long-term success.
B. Screen the child for depression prior to initiating the medication: Although screening for comorbid conditions like depression is important in ADHD management, it is typically part of the initial diagnostic workup, which was already completed with neurology and developmental evaluations.
C. Monitor liver function test results while the child is taking the medication: Atomoxetine carries a risk of rare but serious liver toxicity. Regular monitoring of liver function is essential during treatment, especially if the child shows signs of liver dysfunction (e.g., dark urine, abdominal pain, jaundice).
D. Monitor the child for nightmares while taking the medication: Sleep disturbances, including insomnia and nightmares, are known side effects of atomoxetine. Nurses should monitor and educate caregivers about possible changes in sleep behavior while the child is on this medication.
E.Monitor the child's blood pressure at each visit: Atomoxetine can cause increases in blood pressure and heart rate. Routine monitoring of vital signs at follow-up visits is necessary to ensure cardiovascular safety during treatment.

A. Contact security personnel to place the money in the designated secure location. B. Label the money with the client's name and leave it at the nurses' station. C. Place the money in an envelope in the client's medication drawer. D. Hold the money for the client until their return from surgery.

Correct Answer is A

Explanation

Rationale:

A. Contact security personnel to place the money in the designated secure location: Hospitals have protocols for handling client valuables. The safest and most appropriate action is to notify security so the funds can be securely stored, documented, and returned appropriately. This maintains accountability and protects both the client and staff.

B. Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.

C. Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.

D. Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a pediatric office is assisting in the care of a child. Exhibits A nurse is contributing to the plan of care for a child. Which of the following interventions should the nurse recommend? Select the 4 interventions the nurse should recommend for the child's plan of care.

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is preparing a client for surgery and discovers a large sum of money in the client's wallet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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?