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","E"]
Explanation
Choice A rationale:
Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.
Choice B rationale:
Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.
Choice C rationale:
Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.
Choice D rationale:
Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.
Choice E rationale:
Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.
Correct Answer is B
Explanation
Choice A rationale:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
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