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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Placing the client in Semi Fowler’s position with the head of the bed elevated helps reduce swelling and pressure on the neck after thyroid surgery.
B. Dorsal recumbent position might not provide the necessary support and elevation for the client's neck after thyroid surgery.
C. The supine position might not be as optimal as Semi Fowler’s for comfort and healing after thyroid surgery.
D. The left lateral position is not typically used for postoperative care after a thyroidectomy.
Correct Answer is B
Explanation
A. Loose stools are not a typical finding related to external radiation for throat cancer.
B. Correct. Loss of taste (dysgeusia. is a common side effect of radiation therapy, particularly in the treatment area?
C. Bladder infection is not a typical finding related to external radiation for throat cancer.
D. Increased appetite is not a common finding related to radiation therapy; it's more commonly associated with certain medications or hormonal changes.
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