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 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.
Correct Answer is C
Explanation
Choice A rationale:
Establish learning outcomes. Establishing learning outcomes is an important step in developing an education program, but it should not be the first step. Before setting learning outcomes, the nurse should assess the participants' needs and abilities, which includes determining their literacy level. Without this information, it is difficult to create meaningful and relevant learning outcomes.
Choice B rationale:
Create handouts for participants. Creating handouts is an essential part of the education program, but it should come after determining the literacy level of participants. Handouts should be tailored to the participants' literacy levels to ensure that they can understand and benefit from the materials provided.
Choice D rationale:
Schedule a time to implement the program. Scheduling a time to implement the program is also an important step, but it should not be the first action taken. Before scheduling, the nurse needs to gather information about the participants' needs and abilities to ensure that the program is appropriately designed and timed for their convenience.
Choice C rationale:
Determine the literacy level of participants. Determining the literacy level of participants should be the first action taken when developing an education program for older adults. This step is crucial because it helps the nurse understand the participants' reading and comprehension abilities. It allows the nurse to tailor the program materials and teaching methods to match the literacy level of the group. Older adults may have varying levels of literacy, and customizing the program to their needs will improve its effectiveness and ensure that participants can fully engage and benefit from the educational content.
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