A nurse is teaching a class about incident reports. The nurse should include that which of the following situations requires completion of an incident report?
A client is administered an iron supplement 1 hr after the scheduled time.
A client accidentally pulls out their nasogastric tube.
A client refuses to receive a prescribed treatment.
A client falls getting out of bed.
The Correct Answer is D
Choice A reason: While medication administration should ideally occur within the facility's designated grace period, a 1-hour delay for a non-time-critical supplement like iron typically does not constitute an incident requiring a formal report unless it resulted in a specific adverse clinical outcome or violated strict hospital policy.
Choice B reason: A client pulling out a nasogastric tube is often considered a clinical variance or a change in status rather than an "incident" in the administrative sense. While it must be documented in the medical record and the provider notified, it is generally not handled through the incident reporting system.
Choice C reason: Client refusal of treatment is a right and is documented in the medical record as a refusal of care. This is a matter of autonomy and informed consent rather than an unexpected or accidental event that would necessitate the filing of a formal administrative incident or occurrence report.
Choice D reason: A client fall is a significant safety event that always requires an incident report. These reports are used by risk management and quality improvement committees to analyze the circumstances of the fall, identify contributing factors, and implement systemic changes to prevent future injuries and ensure patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Emic knowledge refers to an "insider's" perspective of a culture. By interviewing members of the culture directly, the nurse gains an understanding of the values, meanings, and beliefs as they are perceived and experienced by the people within that specific cultural group.
Choice B reason: Health disparity data refers to the statistical differences in health outcomes, such as incidence and prevalence of disease, between different population groups. This quantitative data is typically retrieved from public health records and research studies rather than through personal cultural interviews.
Choice C reason: Root cause analysis (RCA) is a structured process used in healthcare to identify the underlying factors that led to a sentinel event or medical error. It is a quality improvement tool and is unrelated to the process of gathering subjective cultural information from community members.
Choice D reason: Etic knowledge refers to an "outsider's" perspective. It involves looking at a culture from the outside using universal categories and scientific theories to describe behavior. Since the nurse is seeking the personal, internal viewpoints of the members, they are seeking emic, not etic, knowledge.
Correct Answer is A
Explanation
Choice A reason: Assessment is always the first step of the nursing process and the teaching process. The nurse must determine if the client is physically, emotionally, and cognitively ready to learn. If the client is in pain or in denial, any educational efforts will be ineffective and wasted.
Choice B reason: Providing written materials is an intervention that occurs during the implementation phase of the teaching plan. Before handing out brochures, the nurse must assess the client's literacy level, preferred learning style, and readiness to ensure that the materials provided are appropriate and will be utilized effectively.
Choice C reason: Identifying goals is part of the planning phase. While goals are essential for measuring the success of the teaching, they cannot be realistically established until the nurse has assessed the client's current knowledge base, physical capabilities, and motivation to manage their diabetes mellitus diagnosis and care.
Choice D reason: Asking for a demonstration is part of the evaluation phase or a later implementation step. This assesses the client's psychomotor skills. However, before asking a client to perform a task, the nurse must first assess if they are ready and willing to engage in the learning process.
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