Which event would require a nurse to complete and file an
incident report?
A client has a seizure.
The nurse determines that a client would benefit from the use of a walker to ambulate.
The nurse, preparing an intrav
...
Which event would require a nurse to complete and file an
incident report?
A client has a seizure.
The nurse determines that a client would benefit from the use of a walker to ambulate.
The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion
pump is not working.
When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure
and takes the visitor to the emergency department for treatment. Correct
Rationale: An incident is any event that is not consistent with the routine
operation of a healthcare unit or routine care of a client. Examples of incidents include client
falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors,
accidental omission of prescribed therapies, and circumstances leading to injury or a risk for
injury. An incident report does not need to be filed if a client has a seizure unless the client
sustains injury as a result of the seizure. If the nurse determines that a client would benefit from
the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the
nurse notes that the battery of an intravenous infusion pump is not working, he or she should
obtain a functioning pump and send the nonfunctioning pump to the appropriate department for
repair.
Test-Taking Strategy: Use the process of elimination and read each option
carefully. Recalling that an incident is any event that is not consistent with the routine operation
of a healthcare unit or routine care of a client will direct you to the correct option. Review the
reasons for filing an incident report if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
336, 337, 403). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Giddens Concepts: Clinical Judgment, Health Policy
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health
Policy/Systems Awarded 1.0 points out of 1.0 possible points.
2.ID: 8482539805A nurse, charting the administration of medications to an
assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am
instead of 9 pm. The nurse checks the client’s vital signs, completes an incident report, and calls
the physician to report the error. The physician tells the nurse that an incident report is not
needed but instructs her to monitor the client during the night for hypotension. What action
should the nurse take?
Notifying the nursing supervisor
Tearing up and discarding the incident report
Telling the physician that the error warrants the completion of an incident report Correct
Telling the nursing supervisor that the physician did not want an incident report completed and
filed
Rationale: Incident reports are an important part of a healthcare agency’s quality
improvement program. An incident is any event that is not consistent with the routine operation
of a healthcare unit or routine care of a client. An example of an incident is administering a
medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an
incident report is completed and filed in accordance with agency guidelines. The nursing
supervisor would be notified of the incident; however, on the basis of the data in the question, the
nurse should tell the physician that the error warrants completion and follow-through with an
incident report. Therefore, the other options are incorrect.
Test-Taking Strategy: Focus on the subject of the question, the physician’s telling
the nurse that an incident report is not needed. Eliminate the options that are comparable or alike
in that they involve notifying the nursing supervisor. To select from the remaining options, recall
the purpose of an incident report to select the correct option. Review the procedures involved in
completing and filing incident reports if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 557, 558). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Giddens Concepts: Clinical Judgment, Health Policy
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Health
Policy/Systems Awarded 1.0 points out of 1.0 possible points.
3.ID: 8482539895Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a
nursing assistant about caring for the client, tells the assistant:
To transfer the client to a semiprivate room
That gloves only are needed to care for the client
To wear gloves and a gown when changing the client's bed linen. Correct
To wear a gown when caring for the client and remove the gown immediately after leaving the
client’s room
Rationale: Contact precautions require the use of gloves, gown, and goggles if
direct client contact is anticipated. Goggles are worn to protect the mucous membranes of the eye
during interventions that may produce splashes of blood or body fluids, secretions, or excretions.
The client should be placed in a private room or, if a private room is not available, in a
semiprivate room with another client who has active infection with the same microorganism but
no other infection. The nursing assistant would remove the protective gear before leaving the
client’s room.
Test-Taking Strategy: Use the process of elimination. Eliminate the option that
includes the closed-ended word “only.” Next eliminate the option that involves removal of the
gown after leaving the client’s room. To select from the remaining options, read each carefully
and visualize the procedure instituted for contact precautions, which will direct you to the correct
option. If you had difficulty with this question, review contact precautions.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
655, 663). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Giddens Concepts: Infection, Leadership
HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded
1.0 points out of 1.0 possible points.
4.ID: 8482539861The mother of a 3-year-old calls a neighbor who is a nurse and
reports that her child just drank some window cleaner that had been stored in a cabinet. The
nurse should instruct the mother to immediately:
Call a poison control center Correct
Administer an excessive amount of fluids to induce vomiting
Call an ambulance to bring the child to the emergency department
Leave a message at the physician answering service about the incident
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