A nurse is reinforcing teaching with a group of newly licensed nurses about completing an incident report. For which of the following situations should the nurse complete an incident report?
A client decides not to have a colonoscopy after signing the consent form.
A client requests to take a shower in the evening rather than in the morning.
A client has an episode of vomiting after receiving medication for hypertension.
A client's family member becomes short of breath and reports having chest pain.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Withdrawing consent is a client’s legal right. No error or unexpected event occurred, so no incident report is required.
Choice B rationale: Preference for shower timing is a routine care adjustment, not an adverse or unusual event requiring documentation.
Choice C rationale: Vomiting may be a side effect, but unless it causes harm or is unexpected, it doesn’t meet incident report criteria.
Choice D rationale: A medical emergency involving a visitor is unexpected and requires documentation for liability, safety, and institutional response tracking.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The nurse should approach the man and ask why he is making copies of the client's medical records. This action allows the nurse to directly address the situation and gather more information before taking further steps.
Option A, may not be the best initial action because it does not directly address the situation.
Option B may be premature without first gathering more information.
Option C, may also not be the best initial action because it does not directly address the situation.
Correct Answer is D
Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Obtaining vital signs on clients who are stable [d] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP. Assisting the client to select a low-residue diet [a] and reviewing the steps of self-blood glucose monitoring with a client [c] involves patient education and dietary planning, which are typically the responsibility of a licensed nurse. Performing a complex dressing change [b] is a complex task that requires specialized knowledge and skills.
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