A nurse is assisting in the care of a group of clients. For which of the following client events should the nurse complete an incident report?

A client has difficulty voiding following the removal of an indwelling catheter

A client reports nausea following the administration of morphine.

A client who has type 2 diabetes mellitus did not eat their breakfast

A client's arm is edematous at the peripheral IV site.

Answer and Explanation

The Correct Answer is D

A. A client has difficulty voiding following the removal of an indwelling catheter: Difficulty voiding can be a common, expected postoperative or post-catheterization occurrence. It requires nursing interventions but does not warrant an incident report unless it results in harm or an adverse outcome.

B. A client reports nausea following the administration of morphine: Nausea is a known and common side effect of opioid medications like morphine. Monitoring and providing antiemetics are appropriate, but this event is anticipated and does not require an incident report.

C. A client who has type 2 diabetes mellitus did not eat their breakfast: Missing a meal may affect blood glucose control but is not considered a reportable incident. Nursing actions would include monitoring glucose and providing alternatives, rather than filing an incident report.

D. A client's arm is edematous at the peripheral IV site: Edema at an IV site may indicate infiltration, phlebitis, or extravasation, which are complications of intravenous therapy. Because it is a preventable or unexpected adverse event, it must be documented in an incident report to inform quality improvement and patient safety measures.

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Correct Answer is C

Explanation

A. Difficulty swallowing: Difficulty swallowing is more commonly associated with cranial nerve involvement, neuromuscular disorders, or medication side effects rather than pain perception. It does not reliably reflect inadequate pain control following a spinal epidural. Difficulty swallowing would prompt evaluation of airway or neurologic status rather than pain relief.

B. Urinary retention: Urinary retention is a known effect of spinal or epidural anesthesia due to temporary blockade of sacral nerves. It reflects autonomic nervous system involvement rather than the client’s pain level. Retention can occur even when pain is adequately managed.

C. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain, especially when pain persists despite treatment. Clients may appear unable to relax, frequently change positions, or seem agitated when discomfort is not controlled. This finding suggests the need for reassessment of pain management effectiveness.

D. Constipation: Constipation is associated with opioid use, reduced mobility, or decreased gastrointestinal motility rather than uncontrolled pain. It develops over time and is not an acute indicator of ineffective pain relief. It would prompt bowel management rather than pain reassessment.

A. Copy of the client's advance directives B. Cause of the client's death C. Location of the identification tag on the client's body D. Last set of the client's vital signs

Correct Answer is C

Explanation

A. Copy of the client's advance directives: Advance directives are part of the client’s legal and medical record but are not included in postmortem documentation. Postmortem charting focuses on care provided after death and body identification rather than prior treatment preferences.

B. Cause of the client's death: Determining and documenting the cause of death is the responsibility of the provider, not the nurse. The nurse may document the time death was pronounced and by whom, but listing the cause exceeds the nursing scope of documentation.

C. Location of the identification tag on the client's body: Proper identification is a critical component of postmortem care to ensure correct body handling and prevent errors. Documenting the placement of identification tags supports legal requirements and continuity of care through the morgue and funeral services.

D. Last set of the client's vital signs: Vital signs are not obtained or documented after death has occurred. Postmortem documentation focuses on confirmation of death, care of the body, and disposition rather than physiological measurements.

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A nurse is assisting in the care of a group of clients. For which of the following client events should the nurse complete an incident report?

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