Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. A nurse observes a client vomiting after receiving an oral pain medication.
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
B. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
C. A nurse discovers that an electronic IV pump.delivered twice the prescribed amount of fluid to a client.
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
D. A nurse discovers that a client's family member has administered a PCA dose.
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.
The following examples may not require an incident report:
A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.
A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.
Similar Questions
A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?
A. "My child still wets the bed at least two times per week."
B. "I have noticed that my child is withdrawn since we switched day care providers."
The guardian's observation about the child being withdrawn since the switch of daycare providers is particularly important. It suggests a change in behavior that could potentially indicate emotional or social difficulties. The nurse should explore this further to gather more information and assess the child's well-being in the new daycare setting. It is essential to ensure the child's emotional health and address any potential issues that may be affecting their well-being and development.
C. "I have a difficult time getting my child to eat green vegetables."
D. "My child continually asks me the same questions."
Full Explanation
The guardian's observation about the child being withdrawn since the switch of daycare providers is particularly important. It suggests a change in behavior that could potentially indicate emotional or social difficulties.
The nurse should explore this further to gather more information and assess the child's well-being in the new daycare setting. It is essential to ensure the child's emotional health and address any potential issues that may be affecting their well-being and development.
A nurse at a provider's office is caring for a client who is in the third trimester of pregnancy.
Which of the following findings should the nurse report to the provider?
A. Shortness of breath when climbing stairs
Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.
B. Leukorrhea
Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.
C. Periodic numbness of the fingers
Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.
D. Blurred vision
Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.
Full Explanation
Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.
Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.
Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.
Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.
A nurse is assisting with the development of an education program for a group of older adults. Which of the following actions should the nurse take first?
A. Establish learning outcomes.
B. Schedule a time to implement the program.
C. Create handouts for participants.
D. Determine the literacy level of participants.
Understanding the literacy level of the older adults is crucial for developing an effective education program. It helps the nurse tailor the content, language, and teaching methods to ensure that the material is accessible and understandable to the participants. By assessing their literacy level, the nurse can identify any potential barriers to learning and make appropriate adjustments to promote effective communication and comprehension.
Full Explanation
Understanding the literacy level of the older adults is crucial for developing an effective education program. It helps the nurse tailor the content, language, and teaching methods to ensure that the material is accessible and understandable to the participants. By assessing their literacy level, the nurse can identify any potential barriers to learning and make appropriate adjustments to promote effective communication and comprehension.
Once the literacy level is determined, the nurse can then proceed with the other actions, such as establishing learning outcomes, scheduling a time to implement the program, and creating handouts that are suitable for the participants' literacy level. However, determining the literacy level should be the first step in order to create an inclusive and effective educational experience for the older adults.