A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report.
Which of the following examples should the nurse include?

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.

A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client.

A nurse discovers that a client's family member has administered a PCA dose.

A nurse observes a client vomiting after receiving an oral pain medication.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.

Choice B rationale:

An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.

Choice C rationale:

Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.

Choice D rationale:

Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.

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Correct Answer is D

Explanation

The correct answer is choiced. “I try not to look at the scales on my body.”

Choice A rationale:Limiting time spent in sunlight is generally a good practice for individuals with psoriasis, as excessive sun exposure can trigger flare-ups or worsen symptoms.

Choice B rationale:Removing old medication before applying a new dose is a proper practice to ensure the effectiveness of the treatment and prevent skin irritation.

Choice C rationale:Avoiding fabric softener is advisable for individuals with psoriasis, as fabric softeners can contain chemicals that may irritate sensitive skin.

Choice D rationale:This statement indicates a potential psychological impact of psoriasis on the client. It suggests that the client might be experiencing distress or avoidance behavior due to the appearance of their skin, which should be reported to the provider for further assessment and support.

A. Assign the client to a negative pressure airflow room. B. Administer aspirin if the client develops a fever. C. Have visitors remain at least 0.91 m (3 feet) away from the client. D. Initiate contact precautions for the client.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: Assigning the client to a negative pressure airflow room is crucial as varicella zoster is highly contagious and can be transmitted through airborne droplets. A negative pressure room helps contain the virus and filters the air, reducing the risk of spread to other patients and healthcare personnel.

Choice B rationale: Administering aspirin is contraindicated in clients with varicella zoster due to the risk of Reye's syndrome, especially in children and adolescents. Aspirin should not be given to children or adolescents with viral infections because it can cause serious complications affecting the liver and brain.

Choice C rationale: Having visitors remain at least 0.91 m (3 feet) away from the client is insufficient. Varicella zoster is highly contagious and requires more stringent airborne precautions, including having visitors wear masks and follow proper hygiene protocols to minimize the risk of transmission.

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A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

Correct Answer is A

Explanation

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.The client becomes agitated and combative when the nurse approaches him.Which of the following actions should the nurse plan to take?

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A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report.
Which of the following examples should the nurse include?