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 B
Explanation
A. Incorrect. The closure of the posterior fontanel by 23 months is a normal developmental milestone.
B. Correct. The anterior fontanel typically closes by 12 to 18 months of age. If it closes prematurely, it could be a sign of craniosynostosis and should be assessed by the provider.
C. Incorrect. Rolling from the back to the abdomen is a normal developmental milestone at around 46 months of age.
D. Incorrect. Moving objects to the mouth is a normal developmental behavior in infants as they explore their environment through sensory input.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
When interpreting test results, particularly for an infectious disease like tuberculosis (TB), the nurse must prioritize specific infection control measures to prevent the spread of the disease.
The correct actions are:
- Wear an N95 respirator mask: This mask is essential for protecting the nurse and others from inhaling airborne pathogens that the client with TB might expel.
- Place the client in a room with negative air pressure: This type of room ensures that airborne contaminants do not escape into the hallway or other areas, thereby containing the infection and protecting others in the healthcare facility.
These measures are critical in managing the spread of TB and ensuring the safety of both healthcare workers and other patients.
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