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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
When reinforcing teaching with a client about advance directives, the nurse should include topics such as organ donation [a], disclosure of personal health care information [b], durable power of attorney for health care [c], and cardiopulmonary resuscitation [e]. Advance directives are legal documents that allow individuals to communicate their wishes about medical treatment and end-of-life care in the event that they are unable to make decisions for themselves. These topics are all important components of advance directives and should be discussed with the client.
Enteral feeding tubes [d] are not a topic that is typically included in discussions about advance directives. While enteral feeding may be a component of end-of-life care, it is not a specific topic that is addressed in advance directives.
Correct Answer is B
Explanation
The nurse should include the statement "Delegation permits a designated individual to meet a goal on your behalf" in the teaching. This is because delegation allows the nurse to assign tasks to an AP who has the appropriate skills and knowledge to complete them, while still maintaining accountability for the outcome of the task.
Option A is incorrect because accountability for a delegated task remains with the delegator, not the AP.
Option C is incorrect because discharge teaching activities for clients cannot be delegated to an AP as they require nursing judgment and assessment.
Option D is incorrect because it is important for the nurse to follow up on delegated tasks even if the AP has completed them before to ensure that they have been completed correctly and that the client's needs have been met.
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