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 reports being dissatisfied with the temperature of the meals provided.

A client receives burns from a heating pad.

A client becomes disoriented and falls out of bed.

A client is unable to afford the physical therapy that the provider recommends.

A client's visitor's getting dizzy and fainting in the client's room

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: A client's dissatisfaction with the temperature of the meals is not an incident that requires a report. The nurse should inform the dietary staff and try to accommodate the client's preferences.

Choice B reason: A client's burns from a heating pad is an incident that requires a report. The nurse should document the cause, extent, and treatment of the burns, as well as the client's response and any actions taken to prevent recurrence.

Choice C reason: A client's disorientation and fall out of bed is an incident that requires a report. The nurse should document the circumstances, injuries, and interventions related to the fall, as well as the client's response and any changes in the plan of care.

Choice D reason: A client's inability to afford the physical therapy is not an incident that requires a report. The nurse should refer the client to a social worker or a financial counselor who can assist with finding resources and options.

Choice E reason: A client's visitor's dizziness and fainting in the client's room is an incident that requires a report. The nurse should document the event, the visitor's condition, and any actions taken to assist the visitor.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.

Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.

Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.

Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.

A. Witness the client’s signature on a consent form. B. Obtain verbal consent from the client. C. Have another nurse co-sign the client’s consent. D. Check the medical record for the client’s signature on a previous consent form.

Correct Answer is B

Explanation

Choice A reason: Witnessing the client’s signature on a consent form is not necessary for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to witness the signature for invasive or high-risk procedures that require written consent.

Choice B reason: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it.

Choice C reason: Having another nurse co-sign the client’s consent is not required for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to have another nurse co-sign the consent for procedures that involve blood transfusions, organ donations, or research participation.

Choice D reason: Checking the medical record for the client’s signature on a previous consent form is not sufficient for verifying the client’s express consent for an indwelling urinary catheter insertion. The nurse should obtain a new consent for each procedure, as the client has the right to change their mind or refuse the treatment at any time.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client’s health record?

Correct Answer is B

Explanation

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client’s express consent for this procedure. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has an NG tube in place for gastric decompression. Which of the following findings should the nurse report to the provider?

A nurse is providing teaching with a client who has severe arthritis and has difficulty with stairs. What should the nurse include in the teaching?

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 nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C?

A nurse is caring for a client who speaks a different language than the nurse and is 5 hours postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

A nurse is reinforcing information with a client who wishes to complete their advance directives. Which of the following statements should the nurse make?

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?