A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?

Nitroglycerin transdermal was applied to a client’s chest.

Cefotaxime was administered to a client after obtaining blood cultures.

Digoxin was administered to a client who has a heart rate of 64/min.

Insulin lispro was administered to a client immediately before bed.

Answer and Explanation

The Correct Answer is D

Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.

Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.

Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.

Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.

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Correct Answer is B

Explanation

Justice is the ethical principle of treating the patient fairly and equally among staff when making assignments. The charge nurse is upholding this principle by ensuring that the workload is distributed evenly and that no staff member is overburdened or underutilized.

Choice A is wrong because Veracity is wrong because veracity is the ethical principle of telling the truth to the patient.

This principle is not relevant to the scenario of making assignments.

Choice C is wrong because Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own healthcare decisions.

This principle is not relevant to the scenario of making assignments.

Choice D is wrong because Fidelity is wrong because fidelity is the ethical principle of keeping promises to the patient.

This principle is not relevant to the scenario of making assignments.

A. Check the back of the throat with a pen light. B. Obtain the child’s vital signs in 15 min. C. Administer analgesia. D. Offer the child a drink of water.

Correct Answer is A

Explanation

A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.

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A nurse is reinforcing teaching with a newly licensed nurse about incident reports. The nurse should identify that which of the following situations requires the completion of an incident report?

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Naxlex Comprehensive Predictor Exams

A charge nurse at a long-term care facility ensures that the workload is distributed equally among staff when making assignments. Which of the following ethical principles is the nurse upholding?

Correct Answer is B

Explanation

A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a newly diagnosed latex allergy. Which of the following foods should the nurse instruct the client to avoid?

A nurse is reviewing the laboratory values for an adolescent who is scheduled for a surgical procedure. For which of the following laboratory values should the nurse notify the provider?

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A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?

A nurse on an inpatient unit is assisting with the discharge plan for a client who has schizophrenia. Which of the following resources should the nurse include in the plan?

A nurse is collecting data from a client who has hypothyroidism. When reviewing the findings and the client’s medical record, which of the following interventions should the nurse suggest to the provider?

A nurse is collecting data from a 24-month-old toddler during an annual physical examination. Which of the following findings should the nurse report to the provider?

A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?