A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA

Include the time the medication error occurred in the report

Identify the medication name and dosage administered to the client in the report

Make a copy of the incident report for personal record keeping

Place a copy of the completed report in the client’s medical record

Obtain an order from the client’s provider to complete the report

Answer and Explanation

Correct Answer : A,B

A. Documenting the time of the error is important for accurately recording when the event happened and for assessing potential impacts on patient care.

B. Including specific details about the medication involved and the dosage is crucial for understanding the nature of the error and for evaluating its potential consequences.

C. Incident reports are confidential and should not be copied for personal records. They are used for internal review and quality improvement purposes and should be handled according to the facility's policies on confidentiality.

D. The incident report should not be placed in the client’s medical record. It is a separate document intended for internal use and quality improvement, not part of the client’s clinical record.

E. No order from the provider is needed to complete an incident report. The report is a standard procedure for documenting and analyzing errors and is part of the facility's protocol for ensuring patient safety.

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Correct Answer is C

Explanation

a. Green:

Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.

b. Yellow:

Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.

c. Black:

The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.

d. Red:

Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.

A. Institute rounds every 2 hr during the day to offer toileting B. Apply vest restraints on residents who are confused C. Accompany residents older than 85 years of age during ambulation D. Keep the four side rails up on beds at night

Correct Answer is A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

c. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

d. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

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A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA

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Correct Answer is C

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