A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

Take the report home and keep it locked up.

Place the report in the client's medical record

Maintain the report according to agency policy

Email the report to their nursing supervisor

Answer and Explanation

The Correct Answer is C

A. Take the report home and keep it locked up: Incident reports are confidential legal documents that must remain within the healthcare facility per policy.

B. Place the report in the client's medical record: Incident reports should not be included in the client’s medical record to prevent liability issues. Instead, objective documentation of the event and any interventions should be recorded in the chart.

C. Maintain the report according to agency policy: The report must be handled per facility protocols, typically submitted to the risk management department to improve patient safety.

D. Email the report to their nursing supervisor: Incident reports contain sensitive information and should be submitted securely following facility policy, not via email.

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Correct Answer is C

Explanation

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

A. Inspect the patient's feet for a diabetic ulcer. B. Expose the full body to ensure efficiency. C. Encourage the patient to provide self-care. D. Apply baby powder to the perineal area and skin folds.

Correct Answer is C

Explanation

A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.

B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.

C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.

D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.

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A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

Nursing Test Bank

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