A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report.
Which of the following examples should the nurse include?
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.
A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client.
A nurse discovers that a client's family member has administered a PCA dose.
A nurse observes a client vomiting after receiving an oral pain medication.
The Correct Answer is B
Choice A rationale:
Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.
Choice B rationale:
An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.
Choice C rationale:
Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.
Choice D rationale:
Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Following a subtotal thyroidectomy, the nurse should position the client in a way that minimizes strain on the surgical site and promotes respiratory function. The most appropriate position for this client is:
d) Semi-Fowler's.
Semi-Fowler's position, where the head of the bed is elevated at a 30 to 45-degree angle, helps reduce swelling at the surgical site and facilitates breathing. This position also minimizes tension on the suture line and aids in preventing strain on the neck.
The other options are not as suitable for post-thyroidectomy positioning:
a) Dorsal recumbent: This position involves lying on the back with the knees flexed. While it might be used in some situations, it doesn't specifically address the considerations after a thyroidectomy.
b) Supine: Lying flat on the back may not provide optimal support to the neck and could potentially increase discomfort.
c) Left lateral: Lying on the left side may not be as effective in reducing strain on the neck and surgical site compared to the semi-Fowler's position.
Correct Answer is D
Explanation
Choice A rationale:
Replace the IV pump's tubing. Replacing the IV pump's tubing is not the appropriate action when the IV pump screen is malfunctioning. Malfunctioning tubing does not typically affect the pump's screen or settings.
Choice B rationale:
Clear the settings and reset the IV pump. Clearing the settings and resetting the IV pump may not be effective if the screen is malfunctioning. It is important to ensure the accuracy and safety of IV fluid administration, and troubleshooting the screen is not a reliable solution in the case of a malfunction.
Choice C rationale:
Plug the IV pump's cord into a different outlet. Changing the outlet may help if the issue is related to electrical power, but it is not the most appropriate action when the IV pump screen is malfunctioning. Safety concerns and potential equipment issues warrant discontinuing use and tagging the pump.
Choice D rationale:
Discontinue use and tag the IV pump. When the IV pump screen is malfunctioning, the safest and most appropriate action is to discontinue its use and tag the pump. This ensures that the malfunctioning equipment is not used on other patients and that a thorough inspection and repair can be conducted to prevent potential harm to the patient.
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