The nurse is preparing to educate a group of graduate nurses about events that should be documented in an incident report. Which examples should the nurse include in the teaching? Select all that apply.
A young female client fell in the shower.
An adolescent client who refused medication.
A client who received an electrical burn in the operating room.
A client who leaves the hospital against medical advice.
Mislabeled medication from the pharmacy.
A confused elderly client who accidentally dislodged their intravenous catheter
Correct Answer : A,C,D,E,F
Rationale:
A. Falls are considered adverse events that may result in injury or potential harm and must be documented in an incident report to identify risks and prevent recurrence.
B. Medication refusal is a patient right and should be documented in the medical record but does not constitute an incident unless it causes harm. Therefore, it typically does not require an incident report.
C. Any injury caused during a procedure is considered an adverse event and requires an incident report to ensure safety review and risk management.
D. Leaving against medical advice (AMA) is a potential safety risk. While the client is exercising autonomy, it is important to document the event in an incident report to protect patient safety and the facility legally.
E. Errors in medication labeling are considered near-miss or actual adverse events. Documenting these in an incident report is crucial for quality improvement and preventing patient harm.
F. Accidental removal of IV lines is an adverse event that can lead to injury or infection. It must be reported to track safety risks and improve care processes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
Rationale:
A. Accurate documentation is not concerning and indicates safe practice. While there are medication administration concerns in prior notes, the statement “accurate documentation” itself does not reflect immediate risk.
B. Frequent, prolonged bathroom breaks can indicate substance use (e.g., diversion of narcotics), avoidance behaviors, or other issues impacting the nurse’s ability to provide safe care. This behavior is a red flag for impaired practice and requires immediate evaluation.
C. Volunteering to work extra shifts or doubles, although potentially stressful, is not an immediate safety concern. While fatigue could affect performance, the behavior itself is not inherently unsafe.
D. Hand tremors may indicate intoxication, withdrawal, or neurological impairment, all of which can directly compromise patient safety. Tremors combined with other cognitive or behavioral changes are significant red flags.
E. Slurred speech is an indicator of possible substance use, medication effect, or other cognitive impairment. Speech difficulties can impair communication with clients and team members, making this an immediate concern.
F. Neglect of personal appearance, such as wearing wrinkled scrubs and avoiding eye contact, is a behavioral indicator of stress, depression, or potential impairment. While not directly harmful to patients, it signals possible broader concerns affecting professional functioning and safety.
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Client 4 is appropriate. The LPN administered oral Warfarin, which is within the LPN scope of practice. Providing a soft toothbrush by the CNA is also appropriate for a client on anticoagulation therapy to reduce bleeding risk. Delegation and supervision are appropriate in this scenario.
B. Client 2 is inappropriate. The RN documented insertion of a nasogastric tube (NGT) and verification of placement by chest x-ray. While RN actions are appropriate, the issue here is not delegation but documentation clarity—however, this scenario does not involve improper delegation to LPN or CNA. The question focuses on delegation errors, and this entry lacks clarity about supervision or role distribution in a complex intervention, making it incomplete in evaluating delegation and therefore problematic.
C. Client 3 is inappropriate. A CNA was sent to the blood bank to pick up a unit of packed red blood cells (PRBCs). This is unsafe and outside the CNA’s scope of practice. Handling blood products requires proper training and adherence to strict protocols, typically performed by licensed personnel. This represents inappropriate delegation.
D. Client 5 is inappropriate. The admission assessment was completed by an LPN. Comprehensive initial assessments for newly admitted clients must be performed by an RN, as they require clinical judgment and critical thinking. This represents inappropriate delegation of an RN responsibility.
E. Client 1 is appropriate. The CNA obtained vital signs and assisted the client with toileting using a bedpan. These tasks fall within the CNA’s scope of practice, and the RN appropriately supervised and documented the care.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.