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 A

Explanation

Rationale:

A. "My advance directives will list what treatments I want if I'm unable to communicate.": Advance directives allow individuals to specify their healthcare preferences in situations where they are incapacitated. This includes decisions about life-sustaining treatments, resuscitation, and other medical interventions.

B. "My advance directives must be signed by my adult child in the presence of a judge.": Advance directives usually require the client’s signature and the signatures of two adult witnesses or notarization, depending on state laws. A judge’s involvement is typically not required.

C. "My family will be informed about my funeral choices in my advance directives.": Funeral or postmortem arrangements are not addressed in advance directives. These documents strictly relate to medical care preferences and decision-making in the event the client becomes unable to speak for themselves.

D. “I can indicate the organs will donate in my advance directives.": While some advance directive forms may include a section about organ donation, formal organ donor registration is typically completed through a driver’s license, organ donor card, or state registry—not as the main purpose of an advance directive.

A. Severe immunodeficiency B. Asymptomatic HIV C. Mild febrile illness D. Egg allergy

Correct Answer is A

Explanation

Rationale:

A. Severe immunodeficiency: The MMR vaccine is a live attenuated vaccine and is contraindicated in clients with severe immunodeficiency, such as those undergoing chemotherapy or with advanced HIV/AIDS. These individuals cannot mount an appropriate immune response, placing them at risk for vaccine-related complications.

B. Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.

C. Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.

D. Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.

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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 reinforcing teaching about advance directives with a client. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to administer a measles, mumps, and rubella (MMR) immunization. Which of the following client characteristics is a contraindication to administration?

Correct Answer is A

Explanation

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