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 A
Explanation
Choice A rationale:
In an interprofessional team meeting for a client, it is essential to include information about changes in the client's condition or any new developments that may impact their care. The statement that "The client has developed difficulty ambulating" is relevant as it indicates a change in the client's mobility status and may require additional interventions or assessments.
Choice B rationale:
The timing of the client's next dressing change (scheduled in 4 hr) is important information but may not be the highest priority to discuss in an interprofessional team meeting. It is more pertinent to focus on the client's current condition and any changes that have occurred.
Choice C rationale:
The client's health insurance status (state-sponsored health insurance) is not typically a central topic of discussion in an interprofessional team meeting unless it directly affects the client's care plan or access to specific treatments.
Choice D rationale:
The frequency of the client's vital sign checks (every 8 hr) is important information for the healthcare team to be aware of, but it may not be the most critical piece of information to include in the interprofessional team meeting. Changes in vital signs or trends would be more relevant to discuss.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should inform the client that they will need periodic TB skin tests to monitor for any reactivation of the infection. This is important for assessing the client's response to treatment and ensuring early detection of any recurrence.
Choice B rationale:
Medications for tuberculosis can cause various side effects, but turning urine a blue-green color is not a common side effect associated with these medications. Providing accurate information about potential side effects is important for informed decision-making, but this statement is not accurate.
Choice C rationale:
The correct response is to inform the client that they are no longer contagious when they have negative sputum cultures. This is an important point to emphasize as it ensures that the client understands when it is safe to be around others without the risk of transmitting the infection.
Choice D rationale:
Telling the client that they will take medication for the rest of their life is incorrect and not appropriate for active pulmonary tuberculosis. Tuberculosis treatment typically involves a combination of medications taken for a specified duration, usually several months, until the infection is effectively treated.
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