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The nurse is teaching a group of students about incident reports. Which of the following situations would require an incident report? A visitor. Select all that apply.
- A. refusing to wear personal protective equipment (PPE).
- B. adjusting a client's infusion pump.
- C. requesting that their family member get pain medication.
- D. assisting their family member with brushing their teeth.
- E. stating that they fell while using the bathroom.
Correct Answer: A, B, E
Rationale: Refusing PPE (A), adjusting an infusion pump (B), and falling in the bathroom (E) are safety incidents requiring reports, as they pose risks or indicate harm. Requesting pain medication (C) and assisting with tooth brushing (D) are not reportable unless escalated.
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The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.
The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?
- A. File an incident report
- B. Assist the child back to bed
- C. Call for help
- D. Assess the child for any injuries
Correct Answer: D
Rationale: Assessing the child for injuries (D) is the priority to identify potential harm, such as head trauma. Calling for help (C), assisting back to bed (B), and filing a report (A) follow after ensuring the child’s safety.
The registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are caring for a client with an infected leg ulcer. Which task should the RN delegate to the LPN/VN?
- A. Obtain wound cultures during dressing changes
- B. Teach the client about high-protein food choices
- C. Assess the risk for further skin breakdown
- D. Initiate an outpatient wound care referral
Correct Answer: A
Rationale: Obtaining wound cultures during dressing changes (A) is a technical task within the LPN’s scope. Teaching (B), risk assessment (C), and referral initiation (D) require RN-level judgment and education skills.
The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority while taking the telephone order?
- A. Verify that the medication is in stock
- B. Read back the prescription to the PHCP
- C. Inform the client of the new prescription
- D. Transmit the prescription to the pharmacy
Correct Answer: B
Rationale: Reading back the prescription to the PHCP (B) is the priority to ensure accuracy and prevent medication errors, a critical safety step in taking telephone orders. Verifying stock (A), informing the client (C), and transmitting to the pharmacy (D) are important but follow confirmation of the order’s correctness.
The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.