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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because measuring the intake and output of a client is a routine task that can be delegated to an AP.
Choice B reason: This is incorrect because reinforcing teaching with a client requires the nurse's knowledge and judgment and cannot be delegated to an AP.
Choice C reason: This is incorrect because assessing the pain level of a client is a nursing responsibility that involves critical thinking and evaluation and cannot be delegated to an AP.
Choice D reason: This is incorrect because checking a client's peripheral IV site for redness or swelling is a nursing skill that requires the nurse's assessment and intervention and cannot be delegated to an AP.
Correct Answer is A
Explanation
Choice A reason: This is correct because a mechanical lift is designed to safely transfer a client who has limited or no mobility and cannot assist with the transfer.
Choice B reason: This is incorrect because the sides of the sling are not for the client to hold onto, but for the nurse to attach the hooks of the lift.
Choice C reason: This is incorrect because the lower end of the sling goes under the client's thighs, not below the client's calves
Choice D reason: This is incorrect because the device does not require the client to use upper body strength, but rather supports the client's weight and movement.
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