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:
Cleansing the skin with an antibacterial soap is not typically recommended for clients with systemic lupus erythematosus (SLE) unless there is a specific medical indication for antibacterial soap. Using mild, non-irritating, hypoallergenic soap is usually preferred to avoid skin irritation in individuals with SLE.
Choice B rationale:
This is the correct answer. Patting the skin dry with a towel instead of rubbing it helps to prevent excessive friction and irritation, which can be particularly important for individuals with SLE who may have sensitive skin. The client demonstrates an understanding of appropriate skin care by choosing this option.
Choice C rationale:
Using an astringent on the face is generally discouraged for individuals with SLE. Astringents can be harsh and may irritate the skin, which can exacerbate skin problems commonly associated with SLE. This statement indicates a misunderstanding of appropriate skin care.
Choice D rationale:
Limiting time in the tanning bed is advisable for anyone, as excessive exposure to UV radiation can increase the risk of skin damage and skin cancers. However, individuals with SLE are especially sensitive to UV radiation, and they should avoid tanning beds altogether. This statement indicates a lack of understanding of the specific needs of individuals with SLE regarding sun exposure.
Correct Answer is D
Explanation
Choice A rationale:
Elevated amylase is not typically associated with cirrhosis. Amylase is an enzyme produced by the pancreas and salivary glands, and elevated levels are more commonly associated with pancreatic disorders or acute pancreatitis.
Choice B rationale:
Decreased bilirubin is not an expected laboratory finding in cirrhosis. Cirrhosis often leads to impaired liver function, which can result in elevated bilirubin levels, causing jaundice.
Choice C rationale:
Elevated lipase is not a characteristic laboratory finding in cirrhosis. Lipase is an enzyme produced by the pancreas, and elevated levels are more often seen in pancreatic disorders or acute pancreatitis.
Choice D rationale:
The correct choice is D. Elevated ammonia levels are commonly associated with cirrhosis. In cirrhosis, the damaged liver is unable to effectively metabolize ammonia, leading to its accumulation in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a neurological complication often seen in cirrhotic patients.
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