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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.
Choice B rationale
Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.
Choice C rationale
A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.
Choice D rationale
Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.
Choice E rationale
Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.
Correct Answer is A,B,C,D,E
Explanation
A. Apply clean gloves.
B. Disconnect the tube from the suction device.
C. Instill 50 mL of air into the tube.
D. Ask the client to take a deep breath.
E. Pinch and withdraw the tube.
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