A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift.
Which of the following statements should the nurse document on the incident report form?

"Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.”

"A nurse accidentally omitted a prescribed dressing change.

"Prescribed dressing change was accidentally omitted during the previous shift.”

"Incident report completed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

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Correct Answer is B

Explanation

Choice A rationale:

Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.

Choice B rationale:

Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.

Choice C rationale:

Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.

Choice D rationale:

Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.

A. Facilitate an interdisciplinary conference at the new facility for the family B. Refer the client and family to a social worker for assistance and a follow-up meeting C. Reassure the client's family that the same provider will provide care at the new facility D. Tell the family that the rehabilitation facility has an excellent client care record

Correct Answer is A

Explanation

A is correct because facilitating an interdisciplinary conference at the new facility for the family can help address their concerns, provide information about the client's plan of care, and promote continuity of care.
B is incorrect because referring the client and family to a social worker for assistance and a follow-up meeting is not enough to address their immediate concerns and does not involve other members of the health care team.
C is incorrect because reassuring the client's family that the same provider will provide care at the new facility may not be true and does not address their specific concerns about the level of care.
D is incorrect because telling the family that the rehabilitation facility has an excellent client care record is not enough to address their specific concerns and may sound dismissive.

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A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?

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Correct Answer is B

Explanation

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift.
Which of the following statements should the nurse document on the incident report form?