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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Laying down immediately after a meal can worsen GERD symptoms. Remaining upright for at least 23 hours after eating is recommended.
B. Incorrect. Eating large meals can exacerbate GERD symptoms. Smaller, more frequent meals are advised.
C. Incorrect. While coffee can trigger GERD symptoms in some, specifying a particular number of cups may not be appropriate. Avoiding triggers and monitoring symptoms is the general advice.
D. Correct. Elevating the head of the bed while sleeping helps prevent stomach acid from flowing back into the esophagus, reducing nighttime GERD symptoms.
Correct Answer is B
Explanation
A. "If you are allergic to gluten you should not receive this vaccine."Gluten allergy is not a contraindication for the MMR vaccine. The vaccine does not contain gluten, and an allergy to gluten would not prevent someone from safely receiving the vaccine. However, individuals with severe allergies to neomycin or gelatin (which are components of the vaccine) should not receive it.
B. "Avoid pregnancy for at least 28 days after receiving the vaccine."The MMR vaccine contains live attenuated viruses, and there is a theoretical risk to the fetus if a woman becomes pregnant shortly after vaccination. Therefore, it is recommended that women avoid becoming pregnant for at least 28 days after receiving the MMR vaccine to reduce any potential risks.
C. "Avoid breastfeeding for 3 days after receiving the vaccine."The MMR vaccine is safe for breastfeeding mothers and does not require any interruption in breastfeeding. The vaccine viruses are not transmitted through breast milk in a way that would harm the infant.
D. "Your partner should also receive the MMR vaccine."While it is important for all individuals to be up-to-date on their vaccinations, the partner's vaccination status is unrelated to the postpartum administration of the MMR vaccine to the client. This instruction does not address a specific concern related to the postpartum period or the MMR vaccine's administration at this time.
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