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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hypercalcemia. Hypercalcemia refers to an elevated level of calcium in the blood. It is not typically a concern in a newborn, and monitoring for hypercalcemia is not necessary in this context. The infant's weight and maternal diabetes are more relevant factors to consider.
Choice B rationale:
Hypobilirubinemia. Hypobilirubinemia implies a low level of bilirubin in the blood, which is not a common concern in newborns, especially in the context of a newborn's weight and maternal diabetes. Monitoring for hyperbilirubinemia, which can lead to jaundice, would be more appropriate.
Choice C rationale:
Hypoglycemia. Hypoglycemia, or low blood sugar, is a significant concern in newborns of diabetic mothers. Newborns born to diabetic mothers are at increased risk of hypoglycemia due to the abrupt cessation of the continuous glucose supply from the mother's bloodstream after birth. Monitoring the newborn's blood glucose levels is crucial in this case.
Choice D rationale:
Decreased RBC. Monitoring for decreased red blood cell (RBC) counts is not typically a primary concern in a newborn, especially one born to a diabetic mother. Hypoglycemia, which can be a result of maternal diabetes, poses a more immediate and significant threat to the newborn's well-being.
Correct Answer is B
Explanation
Choice A rationale:
Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.
Choice B rationale:
Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.
Choice C rationale:
Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.
Choice D rationale:
Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.
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