A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

An approximate amount of urine was recorded after the urine leaked from the client's catheter bag.

A client received an 0900 daily medication at 1000.

A client who has an infection refused the evening meal.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing.

A client fell when ambulating to the bathroom alone.

Answer and Explanation

Correct Answer : A,B,E

The nurse should write an incident report for the following events:
1.   An approximate amount of urine was recorded after the urine leaked from the client's catheter bag. This indicates a potential issue with the catheter or its proper functioning, which needs to be documented and addressed.
2.   A client received an 0900 daily medication at 1000. This is a medication administration error as the medication was given later than the prescribed time. Medication errors should be reported and documented to ensure proper follow-up and prevent future occurrences.
3.   A client fell when ambulating to the bathroom alone. Falls are considered significant incidents and should always be documented and reported to ensure appropriate evaluation, intervention, and prevention of future falls.
The following events do not require an incident report:
A client who has an infection refused the evening meal. While it is important to document a client's refusal of meals, it does not typically warrant an incident report unless there are specific concerns related to the client's health or safety.

A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. This may not require an incident report unless there are specific

circumstances or contraindications related to the timing of the antibiotic administration and blood collection, which need to be documented and reviewed.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.

A. Apply an ice pack to the affected extremity for 20 min every 2 hr. B. Administer aspirin for pain. C. Massage the affected extremity every 4 hr. D. Initiate bed rest.

Correct Answer is D

Explanation

A. Incorrect. Applying an ice pack to the affected extremity is not recommended for a client with deep vein thrombosis, as it could potentially exacerbate the condition by promoting vasoconstriction.
B. Correct. Administering aspirin for pain relief is an appropriate action for a client with deep vein thrombosis. Aspirin has anti-inflammatory and analgesic properties and can help manage pain associated with thrombosis.
C. Incorrect. Massaging the affected extremity is contraindicated for a client with deep vein thrombosis, as it can dislodge the clot and pose a risk of embolization.
D. Incorrect. Initiating bed rest is not recommended for a client with deep vein thrombosis.
Encouraging early ambulation and mobilization can help prevent complications such as thrombus extension and pulmonary embolism.

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A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following Instructions should the nurse give to prepare the client for this test?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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