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 C
An incident report should be completed if a client has an episode of vomiting after receiving medication for hypertension. This is an unexpected event that may indicate an adverse reaction to the medication and requires documentation and follow-up.
Option A does not require an incident report as the client has the right to refuse treatment.
Option B also does not require an incident report as it is a routine request.
Option D may require immediate medical attention, but it does not necessarily require an incident report as it involves a family member rather than a client.
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Correct Answer is B
Explanation
The first action the nurse should take is to speak with the other nurse privately. This allows the nurse to address the mistake in a respectful and professional manner and provide guidance on how to perform the procedure correctly in the future.
Option A is incorrect because correcting the mistake independently does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option C is incorrect because volunteering to perform the procedure next time does not address the underlying issue of the other nurse performing the procedure incorrectly.
Option D is incorrect because submitting an incident report may be necessary, but it should not be the first action taken.
Correct Answer is B
Explanation
If a charge nurse in an acute care facility receives a client request not to have particular assistive personnel (AP) care for her, the appropriate action for the charge nurse to take is to address the concern with the assigned nurse. This will allow the charge nurse and the assigned nurse to work together to address the client's concerns and ensure that the client receives appropriate care.
Option A is incorrect because documenting the issue on an incident report may be necessary, but it should not be the first action taken.
Option C is incorrect because explaining to the client that the AP was having a bad day does not address the client's concerns or wishes.
Option D is incorrect because notifying the human resources department may be necessary, but it should not be the first action taken.
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