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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
Correct Answer is B
Explanation
I should always have my breakfast ready to eat before injecting my morning insulin. This statement confirms that the client understands the importance of matching insulin administration with food intake to prevent hypoglycemia.
Choice A is wrong because hemoglobin A1C should be checked every 3 months, not monthly, to monitor long-term glycemic control.
Choice C is wrong because eating early and taking extra insulin later can cause fluctuations in blood glucose levels and increase the risk of complications.
Choice D is wrong because on sick days, the client should check blood sugar more
often and eat small amounts of carbohydrates to prevent hyperglycemia and ketoacidosis.
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