Which situation requires a nurse to complete an incident report? The nurse:.

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.

Insulin injection sites are rotated to prevent lipodystrophy, which is a condition where the fat tissue under the skin becomes lumpy or dented due to repeated injections.

Lipodystrophy can affect the absorption and effectiveness of insulin.

Choice A is wrong because bruising is not a common complication of insulin

injections. Bruising can occur if the needle hits a blood vessel, but this can be avoided by using a new needle each time and applying gentle pressure after the injection.

Choice B is wrong because infection is not a common complication of insulin

injections. Infection can occur if the skin is not cleaned properly before the injection or if the needle is contaminated, but this can be prevented by washing the hands and using alcohol swabs.

Choice C is wrong because bleeding is not a common complication of insulin

injections. Bleeding can occur if the needle hits a blood vessel, but this can be minimized by using a new needle each time and applying gentle pressure after the injection.