A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
The nurse identifies a broken piece of equipment.
The nurse has a disagreement with the nursing supervisor about inadequate staffing.
A staff member does not show up to work her assigned shift.
A client discovers that his dentures are missing.
The Correct Answer is D
Choice A reason:
The statement “The nurse identifies a broken piece of equipment” is important for safety and should be reported to the appropriate department for repair or replacement. However, it does not typically require an incident report unless the broken equipment caused harm or had the potential to cause harm to a patient. Incident reports are generally used to document events that are not consistent with the routine operation of the healthcare unit or the standard care of a patient.
Choice B reason:
The statement “The nurse has a disagreement with the nursing supervisor about inadequate staffing” reflects an internal issue that should be addressed through appropriate channels, such as a staff meeting or a discussion with human resources. It does not typically require an incident report unless the disagreement led to a situation that compromised patient safety or care. Incident reports are meant to document events that directly affect patient care and safety.
Choice C reason:
The statement “A staff member does not show up to work her assigned shift” is a staffing issue that should be managed by the nursing supervisor or the staffing coordinator. While it can affect the workflow and staffing levels, it does not usually require an incident report unless it directly impacts patient care or safety. Incident reports are used to document specific events that deviate from standard care practices and have the potential to harm patients.
Choice D reason:
The statement “A client discovers that his dentures are missing” is a situation that requires an incident report. The loss of a client’s personal belongings, especially something as essential as dentures, can significantly impact the client’s well-being and quality of care. Documenting this incident helps to investigate the circumstances, prevent future occurrences, and ensure that appropriate measures are taken to address the client’s needs. Incident reports are crucial for tracking and addressing issues that affect patient care and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Walking in front of the client to guide her in moving the walker is not recommended. The nurse should walk beside or slightly behind the client to provide support and ensure safety. Walking in front can obstruct the nurse’s view of the client’s movements and make it difficult to assist if the client loses balance.
Choice B reason:
Ensuring that the upper bar of the walker is level with the client’s waist is incorrect. The correct height for the walker is when the client’s elbows are slightly bent (about 15-30 degrees) when holding the handgrips. This allows for better control and reduces the risk of falls.
Choice C reason:
Having the client move one leg forward with the walker is not the correct technique. The client should first lift the walker and place it a short distance ahead, then step forward with the weaker leg first, followed by the stronger leg. This method provides better stability and support.
Choice D reason:
Checking that the client lifts the walker and then places it down in front of her is the correct action. This ensures that the walker is used properly, providing maximum support and reducing the risk of tripping or falling. The client should lift the walker, move it forward, and then step into the walker area.
Correct Answer is A
Explanation
Choice A reason:
The arterial blood gas (ABG) values of pH 7.26, HCO₃ 14, and PaCO₂ 30 indicate metabolic acidosis with partial respiratory compensation. Acute kidney injury (AKI) often leads to metabolic acidosis due to the kidneys’ inability to excrete acid and reabsorb bicarbonate. The low pH indicates acidosis, the low bicarbonate (HCO₃) reflects metabolic acidosis, and the low PaCO₂ shows that the respiratory system is trying to compensate by blowing off CO₂.
Choice B reason:
The ABG values of pH 7.49, HCO₃ 30, and PaCO₂ 40 indicate metabolic alkalosis. This condition is characterized by an elevated pH and bicarbonate level. Metabolic alkalosis is not typically associated with acute kidney injury. Instead, it can result from excessive bicarbonate intake, loss of gastric acid (e.g., vomiting), or diuretic use.
Choice C reason:
The ABG values of pH 7.26, HCO₃ 24, and PaCO₂ 46 suggest respiratory acidosis. The low pH indicates acidosis, but the normal bicarbonate level and elevated PaCO₂ point to a respiratory cause rather than a metabolic one. Respiratory acidosis occurs when the lungs cannot remove enough CO₂, leading to its accumulation. This is not a typical presentation of AKI.
Choice D reason:
The ABG values of pH 7.49, HCO₃ 24, and PaCO₂ 30 indicate respiratory alkalosis. The high pH and low PaCO₂ suggest that the patient is hyperventilating, leading to excessive CO₂ loss. This condition is not commonly associated with acute kidney injury, which more frequently causes metabolic acidosis.
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