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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Examine the client's upper body for flushing of the skin during the infusion: Red man syndrome is a common adverse effect of rapid IV vancomycin administration. It presents as flushing or rash on the upper body, and monitoring for this reaction is essential to ensure client safety.

B. Monitor for hypertension while the medication infuses: Vancomycin is more commonly associated with hypotension rather than hypertension during infusion, so monitoring for high blood pressure is not a primary concern.

C. Check for a penicillin cross-sensitivity before infusing the medication: Vancomycin is not a beta-lactam antibiotic, so penicillin allergy does not predict vancomycin reactions. Screening for cross-sensitivity is not required.

D. Infuse the medication over 30 min: Rapid infusion increases the risk of adverse effects such as red man syndrome. Vancomycin should typically be infused over at least 60 minutes or longer, depending on the dose, to reduce this risk.

A. Protamine sulfate B. Diphenhydramine C. Bicarbonate D. Naloxone

Correct Answer is C

Explanation

A. Protamine sulfate: Protamine sulfate is an antidote for heparin overdose, not for aspirin toxicity. It does not address salicylate-related symptoms such as tinnitus.

B. Diphenhydramine: Diphenhydramine is an antihistamine used for allergic reactions and motion sickness. It does not counteract aspirin toxicity or reduce salicylate levels.

C. Bicarbonate: Sodium bicarbonate is used in cases of aspirin (salicylate) toxicity to alkalinize the urine, which enhances the renal excretion of salicylates. This intervention helps reduce systemic toxicity, including symptoms like tinnitus.

D. Naloxone: Naloxone is an opioid antagonist used for opioid overdose. It has no effect on aspirin toxicity or salicylate-induced symptoms.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is to receive a prescription for IV vancomycin. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is assessing a client who is taking aspirin and reports having tinnitus. Which of the following medications should the nurse expect to administer?

Correct Answer is C

Explanation

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