Which situation requires a nurse to complete an incident report? The nurse:.

Does not complete the care plan for a newly admitted client before leaving the unit.

Records a client’s refusal to take a prescribed medication on the chart.

Contaminates and discards two indwelling catheters during the insertion procedure.

Experiences back pain after moving a client up in the bed.

Answer and Explanation

The Correct Answer is C

The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.

Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.

It is a matter of time management and prioritization.

Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.

It is a part of the nursing documentation and communication.

Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.

It is a personal injury that may be related to improper body mechanics or ergonomics.

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Correct Answer is D

Explanation

This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.

The other choices are wrong because:

Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.

Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.

Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.

Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.

A. “Older adults often fear becoming addicted to pain medications.”. B. “Older adults often take numerous drugs which can cause interactions with pain medications.”. C. “Confusion and delirium can be a more common reaction to certain pain medications in the elderly.”. D. “Older adults tolerate the same dosage as do younger individuals.”.

Correct Answer is ["D"]

Explanation

Older adults do not have a different pain mechanism and do not feel it as much as younger individuals. This statement is false and indicates the need for further education regarding pain management in older adults.

Some possible explanations for the other choices are:

Choice A is true because older adults often fear becoming addicted to pain medications and may underreport or deny their pain.

Choice B is true because older adults often take numerous drugs that can cause interactions with pain medications and increase the risk of adverse effects.

Choice C is true because confusion and delirium can be a more common reaction to certain pain medications in the elderly, especially opioids and benzodiazepines.

Normal ranges for vital signs in older adults are similar to those in younger adults, except for blood pressure, which may be higher due to arterial stiffness. The normal range for blood pressure in older adults is 120/80 to 140/90 mm Hg.

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Which situation requires a nurse to complete an incident report? The nurse:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is out in public when an individual suddenly falls to the ground with a generalized tonic- clonic (grand mal) seizure. Which action should the nurse take first?

Correct Answer is D

Explanation

Which statement by the student nurse indicates the need for further education regarding pain management in older adults? (Select all that apply).

Correct Answer is ["D"]

Explanation

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