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 receives burns from a heating pad.

A client reports being dissatisfied with the temperature of the meals provided.

A client becomes disoriented and falls out of bed.

A client's visitor becomes dizzy and faints in the client's room.

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

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.

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Correct Answer is A

Explanation

Choice A rationale

Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.

Choice B rationale

Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.

Choice C rationale

Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.

Choice D rationale

Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.

A. Place an identification tag on the outside of the client's shroud. B. Ask the assistive personnel to document the client's time of death. C. Wear sterile gloves when cleaning the client's body. D. Remove the client's dentures and give them to the client's family.

Correct Answer is A

Explanation

Choice A rationale

Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.

Choice B rationale

Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.

Choice C rationale

Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.

Choice D rationale

Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.

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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

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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.)