A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?
A nurse observes a client vomiting after receiving an oral pain medication.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.
A nurse discovers that an electronic IV pump.delivered twice the prescribed amount of fluid to a client.
A nurse discovers that a client's family member has administered a PCA dose.
The Correct Answer is C
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The correct answers are b, c, and d.
a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without
further assessment and evidence.
b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
Correct Answer is B
Explanation
Range-of-motion exercises can be safely performed by assistive personnel under the supervision and direction of the nurse. It helps to maintain the mobility and function of the client's hands while in restraints.
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