A nurse is caring for a group of clients. For which the following situations should the nurse complete an incident report?

A client receives regular insulin 1 hr after a meal.

A client refuses to get out of bed.

A client was scheduled to be discharged 2 hr ago.

A client receives an antibiotic 30 min after the scheduled time.

Answer and Explanation

The Correct Answer is A

A. A client receives regular insulin 1 hr after a meal: Administering insulin outside the recommended timing can cause hypoglycemia or other adverse effects. This medication error is a reportable event, requiring completion of an incident report for documentation and quality improvement.

B. A client refuses to get out of bed: Patient refusal of activity or care is part of routine nursing documentation and does not constitute an incident that requires a formal report unless it results in harm.

C. A client was scheduled to be discharged 2 hr ago: A delayed discharge is an operational issue rather than a clinical incident. It should be addressed in workflow review but does not require an incident report.

D. A client receives an antibiotic 30 min after the scheduled time: A slight delay in routine medication administration is typically documented in the medical record but does not usually meet the threshold for an incident report unless it results in harm or adverse effects.

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Correct Answer is B

Explanation

A. Take the medication in the morning: Simvastatin is more effective when taken in the evening because cholesterol synthesis is higher at night. Taking it in the morning may reduce its lipid-lowering effect.

B. Report muscle tenderness: Muscle pain, tenderness, or weakness can indicate myopathy or rhabdomyolysis, serious adverse effects of statins. Clients should report these symptoms promptly for evaluation and possible medication adjustment.

C. This medication can cause kidney damage: Simvastatin primarily affects the liver and muscles. While rhabdomyolysis can indirectly impact kidney function, kidney damage is not a common direct effect of the medication.

D. Avoid drinking grapefruit juice for 3 hr after taking this medication: Grapefruit juice can inhibit metabolism of simvastatin, increasing the risk of toxicity. Avoiding grapefruit entirely, rather than timing it around the dose, is the recommended precaution.

A. Insert the needle into the dermis layer of skin. B. Inject the medication slowly with the skin pulled taut. C. Cleanse the skin using a circular motion. D. Produce a small wheal on the surface of the skin. E. Hold the needle with the bevel facing up.

Correct Answer is C,E,A,B,D

Explanation

C. Cleanse the skin using a circular motion: Cleaning the site first prevents infection and prepares the area for safe injection. Using a circular motion from the center outward helps remove microorganisms without contaminating the injection site.

E. Hold the needle with the bevel facing up: Positioning the needle bevel up ensures a smoother entry into the dermis and reduces tissue trauma, which is important for accurate intradermal administration.

A. Insert the needle into the dermis layer of skin: The needle is inserted at a very shallow angle into the dermis. Proper placement is essential for the tuberculin test to produce a valid reaction.

B. Inject the medication slowly with the skin pulled taut: Slowly injecting the medication ensures it remains in the dermis and prevents leakage into subcutaneous tissue. Pulling the skin taut stabilizes the area and allows for precise administration.

D. Produce a small wheal on the surface of the skin: The appearance of a small, raised wheal confirms that the medication has been correctly administered intradermally. This wheal is necessary for the subsequent reading of the tuberculin test.

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A nurse is caring for a group of clients. For which the following situations should the nurse complete an incident report?

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is preparing to administer an intradermal injection for a tuberculin screening. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,E,A,B,D

Explanation

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