Admission Assessment Day 1, 1000:

An older adult client was transferred to the ICU after they developed fever and hypotension. The client was initially admitted 4 days ago with a left hip fracture and subsequently underwent total left hip arthroplasty. The client is alert and oriented to person, place, and time. The client's partner is at the bedside.

Past Medical History: hypertension, congestive heart failure, Parkinson's disease

Allergies: penicillin (anaphylaxis)

Social History: Client has visual loss but didn't bring their glasses. The client is hard of hearing.

Hearing aids in place.

Which of the following actions should the nurse take? Select all that apply.

An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.

In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.

The other examples listed may require further actions but may not necessarily require an incident report:

1. A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
2. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
3. A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.

A. Write the information at an 8th-grade reading level: This is a good practice. Writing at an 8th-grade reading level ensures that the brochure is understandable for a wide audience, including those with varying levels of literacy. It helps make the information clear and accessible.

B. Present information from complex to simple: This approach is not ideal. It is generally more effective to present information from simple to complex to build understanding progressively. Starting with basic concepts helps the reader grasp foundational information before moving to more detailed content.

C. Explain medical terminology using basic, one-syllable words: While using simple language is important, basic, one-syllable words might not always be appropriate for explaining medical terminology accurately. It is better to use plain language that conveys the meaning clearly, rather than overly simplifying complex terms.

D. Use a 12-point font size: Using a 12-point font size is generally appropriate and readable for most brochures. However, depending on the audience, a slightly larger font size (e.g., 14-point) may be preferable to enhance readability.