A nurse is caring for a group of clients.
For which of the following situations should the nurse complete an incident
report? (Select all that apply.).
A client is unable to afford the physical therapy that the provider recommends.
A client reports being dissatisfied with the temperature of the meals provided.
A client’s visitor becomes dizzy and faints in the client’s room.
A client receives burns from a heating pad.
A client becomes disoriented and falls out of bed.
Correct Answer : C,D,E
The correct answer is choice C, D, and E.
Choice A rationale: A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.
Choice B rationale: A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.
Choice C rationale: A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.
Choice D rationale: A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.
Choice E rationale: A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.
The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.
The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.
The client should keep a slight bend in the elbows when walking with crutches
Correct Answer is A
Explanation
This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.
The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.
Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before following any protocol.
Choice C is wrong because reporting defective equipment is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.
Choice D is wrong because requesting a replacement device is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before requesting a new one.
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