A nurse is using incident reports with a group of newly licensed nurses. The nurse should include in the discussion that which of the following situations requires completion of an incident report?

A nurse finds medication on the client’s bedside table upon entering the room.

A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500

A client's medication record MARI indicates the 0800 dose of morphine was withheld because the client refused to take the medication

A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the clients bedside

Answer and Explanation

The Correct Answer is B

Rationale:

A. A nurse finds medication on the client’s bedside table upon entering the room: While this is a safety concern, it may not necessarily require an incident report unless it resulted in harm or was due to a medication error. It should be documented and investigated, but may not meet the threshold for a formal report depending on facility policy.

B. A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500: This represents a medication administration error—giving the drug significantly earlier than prescribed. Administering time-sensitive medications outside the scheduled time can affect patient safety and should be reported using an incident report for evaluation and prevention.

C. A client's MAR indicates the 0800 dose of morphine was withheld because the client refused to take the medication: Client refusal of medication is not an error and does not require an incident report. It should be documented in the medical record along with any related assessments or follow-up, but it is not a reportable incident.

D. A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the client’s bedside: This situation suggests a delay in removing the IV bag, which is a minor deviation from ideal practice but typically does not require an incident report unless there was harm, contamination, or risk of adverse outcome.

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Correct Answer is B

Explanation

Rationale:

A. Collecting a clean catch urine specimen: This is within the nurse’s scope of practice and is a routine part of preoperative preparation to screen for infection or other abnormalities before surgery.

B. Explaining the risks of the procedure: Explaining surgical risks is the responsibility of the provider performing the procedure. Nurses may reinforce information but are not authorized to introduce or explain risks, as this constitutes part of informed consent.

C. Reinforcing preoperative teaching: Reinforcement of teaching provided by the surgeon or anesthesiologist is within the nurse’s role. The nurse can clarify instructions or ensure the client understands how to prepare for surgery based on what was already explained.

D. Performing a preoperative skin preparation: Nurses are responsible for tasks like preoperative skin prep, which helps reduce infection risk. This is a common nursing duty that supports surgical readiness.

A. Speech pathologist B. Respiratory therapist C. Occupational therapist D. Physical therapist E. Pharmacist

Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. Speech pathologist: A speech pathologist evaluates and treats dysphagia (difficulty swallowing) and communication impairments following a stroke. This referral is essential to assess swallowing safety and prevent aspiration.

B. Respiratory therapist: A respiratory therapist assists with pulmonary care, oxygen therapy, or ventilatory support. Unless the client has respiratory complications, a referral is not typically indicated solely for stroke-related weakness or swallowing difficulty.

C. Occupational therapist: An occupational therapist helps the client regain the ability to perform daily activities (e.g., dressing, grooming) that may be impaired by right-sided weakness. This referral supports independence and rehabilitation.

D. Physical therapist: A physical therapist works to improve mobility, balance, and strength in clients with musculoskeletal impairments after a stroke. Right-sided weakness makes this referral highly appropriate for motor recovery.

E. Pharmacist: A pharmacist ensures appropriate medication management, but a direct referral is not typically required for stroke rehabilitation unless there are specific medication concerns or complexities.

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A nurse is using incident reports with a group of newly licensed nurses. The nurse should include in the discussion that which of the following situations requires completion of an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is preoperative for a surgical procedure. The nurse should identify that which of the following tasks is outside of their scope of practice?

Correct Answer is B

Explanation

A nurse is caring for a client who has right-sided weakness and difficulty swallowing after a stroke. The nurse should ensure the client has referrals to which of the following members of the interprofessional care team? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is contributing to the plan of care for a client who has a gambling disorder. Which of the following nursing interventions should the nurse include in the plan of care?

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

A nurse is assisting in the care of a group of clients. Which of the following clients should the nurse identify as being at an increased risk for physical injury?

A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is assisting in the care of a client who is scheduled for surgery. Which of the following steps should the nurse take prior to witnessing informed consent?

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A nurse is assisting with the care of a client and asks the client. "Can you tell me about your day so far?" Which of the following therapeutic techniques is the nurse using?

A nurse is collecting data from a newborn who was born 24 hr ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?