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.)

A client who has an infection refused the evening meal.

A client fell when ambulating to the bathroom alone.

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

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

A client received an 0900 daily medication at 1000.

Answer and Explanation

Correct Answer : B,C,D,E

The correct answers are Choices B, C, D, and E.

Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.

Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.

Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.

Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.

Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["D","E","F"]

Explanation

Choice A rationale:

Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.

Choice B rationale:

Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.

Choice C rationale:

Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.

Choice D rationale:

Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.

Choice E rationale:

The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.

Choice F rationale:

Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.

A. Instruct the client to take a brisk walk. B. Position the client on their left side. C. Check the client's temperature. D. Provide the client with a glass of orange juice.

Correct Answer is B

Explanation

Choice A rationale:

"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.

Choice B rationale:

"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.

Choice C rationale:

"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.

Choice D rationale:

"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is ["D","E","F"]

Explanation

A nurse is collecting data from a client during a routine prenatal visit.The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation.Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?

A nurse is assisting with planning an in-service for staff members about active shooter protocols. Which of the following information should the nurse recommend including?

A nurse begins to bathe a newly admitted client who reports that they have not had anything to eat that day. The nurse interrupts the bath and obtains a healthy meal for the client. This action by the nurse is an example of which of the following?

A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?

A nurse is assisting with a community health education program about childhood communicable diseases.Which of the following information should the nurse include in the presentation?

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

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.)