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 B
Explanation
Choice A rationale:
While vitamin D is essential for bone health and wound healing, it is not the primary nutrient to focus on in this case. Protein plays a crucial role in wound healing because it is necessary for tissue repair and the production of collagen, which is essential for wound closure.
Choice B rationale:
Increasing protein intake is the correct choice. Proteins are the building blocks of tissue repair and wound healing. Adequate protein intake is essential for promoting the healing of open wounds.
Choice C rationale:
Calcium is important for bone health but is not the primary nutrient to address in this situation. Calcium is not directly involved in wound healing processes.
Choice D rationale:
Fats are necessary for overall health, but they do not have a direct role in wound healing. Protein intake is more critical in this context to promote tissue repair and healing.
Correct Answer is A
Explanation
Choice A rationale:
"Nervousness." Rationale: This is a correct instruction. Thyrotoxicosis is a condition characterized by excessive thyroid hormone production. Common symptoms include nervousness, anxiety, restlessness, and emotional instability. The client should notify the healthcare provider if they experience these symptoms as they may indicate an excessive dose of levothyroxine.
Choice B rationale:
"Cough." Rationale: Cough is not typically associated with thyrotoxicosis. Symptoms of thyrotoxicosis are primarily related to an overactive thyroid gland and may include palpitations, weight loss, heat intolerance, and nervousness.
Choice C rationale:
"Pruritus." Rationale: Pruritus (itching) is not a common symptom of thyrotoxicosis. Itchy skin is more likely related to other dermatological or systemic conditions and should be evaluated separately.
Choice D rationale:
"Polyuria." Rationale: Polyuria (excessive urination) can be associated with both hypothyroidism and hyperthyroidism, but it is not a typical manifestation of thyrotoxicosis. Increased urination is more commonly seen in conditions like diabetes mellitus. Therefore, polyuria alone may not be indicative of thyrotoxicosis in this context.
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