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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Hospice care is typically recommended for clients with a terminal illness who are no longer seeking curative treatment. It may not be suitable for an older adult with early onset dementia unless their condition is very advanced.

Choice B rationale:

Recommending an adult day care facility is appropriate in this situation. Adult day care centers provide a safe and stimulating environment for older adults who require supervision and socialization during the day. It can be a helpful resource for the client's care while the adult child is at work.

Choice C rationale:

Suggesting a community senior center is a good option for social engagement and activities, but it may not provide the level of supervision and care needed for an older adult with dementia, especially if the adult child works full-time.

Choice D rationale:

Recommending a long-term care facility is a more drastic step and is typically considered when a client's care needs cannot be met at home or in less restrictive settings. It may not be necessary for a client with early onset dementia who still has family support.

A. Hypertension. B. Constipation. C. Muscle cramps. D. Blurred vision.

Correct Answer is C

Explanation

Choice A rationale:

Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.

Choice B rationale:

Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.

Choice C rationale:

Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.

Choice D rationale:

Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is assisting with the discharge of an older adult client who has early onset dementia and lives with their adult child who works full time.Which of the following resources should the nurse recommend to the family to assist with the client's care?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has hyponatremia.Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is obtaining informed consent from a client who is scheduled for an invasive procedure. The client states, "I don't understand why this procedure is necessary." Which of the following actions should the nurse take?

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?

A nurse is documenting client care in the nurses' notes and notices that a space was left blank.Which of the following actions should the nurse take?

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching?

A nurse in a provider's office is collecting data from a client who has candidiasis.Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who states, "My doctor was just here, but I still do not understand my diagnosis." The nurse contacts the provider to return to speak with the client.Which of the following principles is the nurse demonstrating?

A nurse is assisting with the development of an education program for a group of older adults.Which of the following actions should the nurse take first?

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?