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 A

Explanation

Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.

Choice B is wrong because fine motor tremors are not related to speech or language problems.

They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.

Choice C is wrong because facial flushing is not related to speech or language problems.

It may be caused by high blood pressure, fever, anxiety or other conditions.

Choice D is wrong because urinary incontinence is not related to speech or language problems.

It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.

A. Contact information for a community mental health center. B. A list of primary prevention activities. C. Contact information for enrollment in a 12-step program. D. A referral for respite care services.

Correct Answer is A

Explanation

Contact information for a community mental health center. A community mental health center can provide ongoing outpatient care and support services for a client who has schizophrenia after discharge from an inpatient unit. A community mental health center can also help the client access other resources such as medication, housing, and vocational training.

Choice B is wrong because a list of primary prevention activities is not relevant for a client who already has schizophrenia. Primary prevention aims to prevent the occurrence of a disease or disorder in the first place.

Choice C is wrong because contact information for enrollment in a 12-step program is not appropriate for a client who has schizophrenia unless they also have a substance use disorder. A 12-step program is a self-help group that follows a set of principles to achieve and maintain sobriety.

Choice D is wrong because a referral for respite care services is not necessary for a client who has schizophrenia unless they also have a caregiver who needs temporary relief from their caregiving duties. Respite care services provide short-term care for clients who are dependent on others for their daily needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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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?