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 is demonstrating advocacy by contacting the provider to return and speak with the client when the client expresses a lack of understanding about their diagnosis. Advocacy involves promoting the client's best interests, ensuring they receive appropriate information and care, and facilitating communication between the client and the healthcare team to address their concerns and needs.

Choice B rationale:

Good manners, while important in nursing practice, do not capture the essence of the nurse's action in this scenario. The nurse's primary role is to advocate for the client's understanding and communication with the healthcare provider.

Choice C rationale:

Customer service is not the primary focus in this situation. While providing excellent customer service is important in healthcare, the nurse's primary responsibility is to ensure the client's understanding of their diagnosis and address any questions or concerns they may have.

Choice D rationale:

Kindness is a positive quality in nursing practice, but it does not fully encompass the nurse's role in this scenario. The nurse's primary responsibility is to advocate for the client's understanding and facilitate effective communication with the provider to address the client's concerns and questions.

A. "Colostrum provides many important antibodies that the newborn lacks.” B. "Colostrum provides vitamin K, which is an essential nutrient for newborns.” C. "Colostrum contains iron, which is important for a newborn's brain development.” D. "Colostrum contains a natural diuretic that stimulates the newborn to void.”

Correct Answer is A

Explanation

Choice A rationale:

Colostrum, the initial breast milk produced after childbirth, is crucial for a newborn's health because it contains a high concentration of antibodies, also known as immunoglobulins (IgA), which provide passive immunity to the baby. These antibodies are essential because a newborn's immune system is immature and not yet capable of producing its antibodies. IgA antibodies in colostrum help protect the baby against various infections, including respiratory and gastrointestinal illnesses. Therefore, choice A is the correct answer as it accurately reflects the importance of colostrum in providing immune protection for the newborn.

Choice B rationale:

Colostrum does not primarily provide vitamin K. While vitamin K is essential for newborns to prevent bleeding disorders, it is not the primary function of colostrum. Colostrum's primary role is to provide immune protection.

Choice C rationale:

Colostrum does contain trace amounts of iron, but its iron content is not the primary reason for its importance. Iron stores in a newborn's body are typically established during the third trimester of pregnancy, and colostrum is not a significant source of iron for the baby. The primary role of colostrum is to provide antibodies, not iron.

Choice D rationale:

Colostrum does not contain a natural diuretic. Its purpose is not to stimulate the newborn to void. Instead, it focuses on providing immune protection and essential nutrients for the baby's initial growth and development.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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?