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 ["675"]
Explanation
Step 1: Convert the client’s weight from pounds to kilograms. 198 lb ÷ 2.2 = 90 kg
Result: 90 kg
Step 2: Calculate the total daily dose of vancomycin. 15 mg × 90 kg = 1350 mg/day
Result: 1350 mg/day
Step 3: Divide the total daily dose by 2 to get the dose per administration (since it is given every 12 hours). 1350 mg/day ÷ 2 = 675 mg
Result: 675 mg
Final Answer: The nurse should administer 675 mg of vancomycin with each dose.
Correct Answer is A
Explanation
Choice A reason:
A decrease in heart rate is a key indicator of adequate fluid resuscitation in burn patients. When a patient is adequately hydrated, the heart does not need to work as hard to pump blood, leading to a lower heart rate. This is because fluid resuscitation helps restore blood volume, improving cardiac output and reducing the strain on the heart. Normal heart rate ranges for adults are typically between 60-100 beats per minute.
Choice B reason:
While blood pressure is an important parameter to monitor, a decrease in blood pressure is not an indication of adequate fluid replacement. In fact, adequate fluid resuscitation should help maintain or increase blood pressure to normal levels. Low blood pressure could indicate hypovolemia or inadequate fluid resuscitation3. Normal blood pressure ranges are generally considered to be around 120/80 mmHg.
Choice C reason:
A decrease in urine output is not a sign of adequate fluid resuscitation. On the contrary, adequate fluid replacement should result in an increase in urine output as the kidneys receive sufficient blood flow to filter and excrete waste products. Urine output is a critical marker for assessing fluid balance, with normal output being about 0.5-1 mL/kg/hr.
Choice D reason:
A decrease in weight is not an immediate indicator of adequate fluid resuscitation. Weight changes can occur over a longer period and are influenced by various factors, including fluid shifts, edema, and overall fluid balance. In the acute phase of burn management, more immediate indicators like heart rate and urine output are more reliable.
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