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 A

Explanation

Choice A rationale:

The nurse should respond by offering to show the client how to swaddle and cuddle the newborn and then encourage the client to try it herself. This response promotes bonding between the mother and newborn and empowers the client to care for her baby, building her confidence and self-esteem.

Choice B rationale:

Taking the newborn back to the nursery without involving the mother does not support maternal-infant bonding and does not address the client's feelings of inadequacy. It is essential to encourage maternal involvement in infant care.

Choice C rationale:

Turning the newborn on his side without addressing the client's concerns does not provide emotional support or guidance on infant care. It is important to respond to the client's emotional needs and offer assistance in caring for the baby.

Choice D rationale:

Telling the client that babies need to cry to develop their lungs is not an appropriate response to the client's distress. It does not address the client's concerns or provide helpful guidance on caring for the newborn.

A. "I need to use iodine to disinfect cuts on my feet.” B. "I will wear a clean pair of cotton socks each day.” C. "I should soak my feet in warm water every morning.” D. "I can remove ingrown toenails at home as needed.”

Correct Answer is B

Explanation

Choice A rationale:

Using iodine to disinfect cuts on the feet is not recommended for individuals with diabetes. Iodine can be harsh and may delay wound healing. It's better to clean cuts with mild soap and water and consult a healthcare professional for proper wound care.

Choice B rationale:

Wearing a clean pair of cotton socks each day is an excellent practice for someone with diabetes. Cotton socks can help absorb moisture and reduce the risk of fungal infections and pressure sores.

Choice C rationale:

Soaking feet in warm water every morning is not recommended for individuals with diabetes, as it can lead to skin drying and cracking. It's better to soak feet in lukewarm water occasionally, not daily, and to moisturize afterward.

Choice D rationale:

Attempting to remove ingrown toenails at home is not advisable for individuals with diabetes, as it can lead to infection and complications. Clients with diabetes should seek professional foot care for any foot issues, including ingrown toenails.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?