A nurse is caring for a client who is receiving positive pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply)

Choice A reason:

The statement “The nurse identifies a broken piece of equipment” is important for safety and should be reported to the appropriate department for repair or replacement. However, it does not typically require an incident report unless the broken equipment caused harm or had the potential to cause harm to a patient. Incident reports are generally used to document events that are not consistent with the routine operation of the healthcare unit or the standard care of a patient.

Choice B reason:

The statement “The nurse has a disagreement with the nursing supervisor about inadequate staffing” reflects an internal issue that should be addressed through appropriate channels, such as a staff meeting or a discussion with human resources. It does not typically require an incident report unless the disagreement led to a situation that compromised patient safety or care. Incident reports are meant to document events that directly affect patient care and safety.

Choice C reason:

The statement “A staff member does not show up to work her assigned shift” is a staffing issue that should be managed by the nursing supervisor or the staffing coordinator. While it can affect the workflow and staffing levels, it does not usually require an incident report unless it directly impacts patient care or safety. Incident reports are used to document specific events that deviate from standard care practices and have the potential to harm patients.

Choice D reason:

The statement “A client discovers that his dentures are missing” is a situation that requires an incident report. The loss of a client’s personal belongings, especially something as essential as dentures, can significantly impact the client’s well-being and quality of care. Documenting this incident helps to investigate the circumstances, prevent future occurrences, and ensure that appropriate measures are taken to address the client’s needs. Incident reports are crucial for tracking and addressing issues that affect patient care and safety.

Choice A reason:

Urinary hesitancy, while concerning, is not typically an immediate threat to the client’s health. It can indicate underlying issues such as benign prostatic hyperplasia (BPH) or urinary tract infections, which require medical attention but are generally not life-threatening. Addressing urinary hesitancy is important, but it does not take precedence over more acute conditions.

Choice B reason:

Swollen gums can be a sign of poor oral hygiene, gingivitis, or other dental issues. While important to address, swollen gums are not usually an immediate threat to the client’s overall health. Dental issues can lead to complications if left untreated, but they do not typically require urgent intervention.

Choice C reason:

Dysphagia, or difficulty swallowing, is a priority because it can lead to serious complications such as aspiration pneumonia, malnutrition, and dehydration. Aspiration pneumonia occurs when food or liquid enters the lungs, leading to infection. Dysphagia can also cause significant discomfort and impact the client’s ability to eat and drink adequately, making it a critical issue to address promptly.

Choice D reason:

Pruritus, or itching, can be a symptom of various conditions, including allergies, skin disorders, or systemic diseases such as liver or kidney problems. While pruritus can be very uncomfortable and impact the client’s quality of life, it is not typically an immediate threat to health. It requires assessment and management but is not as urgent as dysphagia.