A charge nurse is discussing incident reports with a newly licensed nurse. Which of the following situations should the nurse identify as requiring an incident report?
A client refuses to attend physical therapy.
A visitor pinches his finger in the client's bed frame.
A client throws a box of tissues at a nurse.
A nurse administers a medication 30 min after the scheduled time.
The Correct Answer is B
Rationale:
A. A client refusing therapy is not an unusual occurrence and does not require an incident report—this should be documented in the nursing notes instead.
B. An injury to a visitor, staff, or client is considered an unusual event and requires an incident report for risk management and safety follow-up.
C. A client throwing tissues may be disruptive, but since no injury or safety issue occurred, an incident report is not required. Documentation of behavior is sufficient.
D. Administering medication 30 minutes late is generally within the accepted time frame for most scheduled medications and does not require an incident report.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A living will provides instructions for end-of-life care but does not authorize emergency surgical procedures.
B. The Good Samaritan Act protects healthcare providers who give emergency care outside a healthcare setting, not in-hospital surgical consent.
C. Joint liability refers to shared legal responsibility and is not related to consent for treatment.
D. Implied consent allows healthcare providers to perform emergency procedures when a client is unconscious or unable to give consent, and no legal representative is available, making it the correct legal guideline in this scenario.
Correct Answer is C
Explanation
Rationale:
A Visitors for a client on contact precautions (e.g., MRSA, C. diff) need gloves and gown, not a mask, unless droplet or airborne precautions are also indicated.
B. A client with compromised immunity requires protective isolation in a positive-pressure airflow room, not a negative-pressure one (which is for airborne infections).
C. Clients on airborne precautions (e.g., TB, measles, varicella) must wear a surgical mask if they leave their room to prevent spreading infectious particles.
D. An N95 respirator is used for airborne precautions, not droplet. Droplet precautions (e.g., influenza, pertussis) only require a surgical mask within 3 feet of the client.
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