A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?

Record in the nurse's notes that an incident report was filed.

Give the family a copy of the incident report.

Document the facts about the incident in the medical record.

Place a copy of the incident report in the medical record.

Answer and Explanation

The Correct Answer is C

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.
B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.
C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.
D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

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Correct Answer is A

Explanation

A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.
B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.
C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.
D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture. D. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster.

Correct Answer is C

Explanation

A. Placing a midstream urine sample in a specimen refrigerator is an appropriate practice and does not pose an infection control hazard.
B. Wiping a countertop with chlorhexidine solution is a correct practice following a blood spill and contributes to infection control.
C. Pouring sterile 0.9% sodium chloride irrigation solution directly onto an open pressure wound before collecting a specimen poses an infection control hazard, as it can introduce contaminants to the wound and affect the culture results.
D. Using alcohol-based antiseptic to clean hands after interacting with a client who has varicella zoster is an appropriate infection control measure and reduces the risk of spreading infection.

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A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

Correct Answer is C

Explanation

A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

A nurse is assisting with the planning of an in-service for a group of newly licensed nurses about transcribing prescriptions from a provider. Which of the following examples should the nurse include as an approved abbreviation?

A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?

A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is assisting with the discharge of a client who is postoperative following a total knee arthroplasty. The client lives alone and does not have any friends or relatives who live close by. Which of the following actions should the nurse plan to take?

A nurse is collecting data from an older adult client during a home visit. Which of the following findings should the nurse report?

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.