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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Cleansing the skin with an antibacterial soap is not typically recommended for clients with systemic lupus erythematosus (SLE) unless there is a specific medical indication for antibacterial soap. Using mild, non-irritating, hypoallergenic soap is usually preferred to avoid skin irritation in individuals with SLE.

Choice B rationale:

This is the correct answer. Patting the skin dry with a towel instead of rubbing it helps to prevent excessive friction and irritation, which can be particularly important for individuals with SLE who may have sensitive skin. The client demonstrates an understanding of appropriate skin care by choosing this option.

Choice C rationale:

Using an astringent on the face is generally discouraged for individuals with SLE. Astringents can be harsh and may irritate the skin, which can exacerbate skin problems commonly associated with SLE. This statement indicates a misunderstanding of appropriate skin care.

Choice D rationale:

Limiting time in the tanning bed is advisable for anyone, as excessive exposure to UV radiation can increase the risk of skin damage and skin cancers. However, individuals with SLE are especially sensitive to UV radiation, and they should avoid tanning beds altogether. This statement indicates a lack of understanding of the specific needs of individuals with SLE regarding sun exposure.

A. "I limit my time spent out in the sunlight.” B. "I remove old medication on my skin before applying a new dose.” C. "I do not use fabric softener when I wash my clothing.” D. "I try not to look at the scales on my body.”

Correct Answer is D

Explanation

The correct answer is choiced. “I try not to look at the scales on my body.”

Choice A rationale:Limiting time spent in sunlight is generally a good practice for individuals with psoriasis, as excessive sun exposure can trigger flare-ups or worsen symptoms.

Choice B rationale:Removing old medication before applying a new dose is a proper practice to ensure the effectiveness of the treatment and prevent skin irritation.

Choice C rationale:Avoiding fabric softener is advisable for individuals with psoriasis, as fabric softeners can contain chemicals that may irritate sensitive skin.

Choice D rationale:This statement indicates a potential psychological impact of psoriasis on the client. It suggests that the client might be experiencing distress or avoidance behavior due to the appearance of their skin, which should be reported to the provider for further assessment and support.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements by the client should the nurse report to the provider?

Correct Answer is D

Explanation

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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?