Question 1 pts
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.
Co
orrrec
ct!
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.
, Rationale: An incident is any event that is not consistent
with the routine operation of a health care 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 knowledge of the subject,
reasons for filing an incident report, to assist you with the
process of elimination. Read each option carefully.
Recalling that an incident is any event that is not
consistent with the routine operation of a health care 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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 2
A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that
atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse
checks the client’s vital signs, completes an incident report,and calls the health care provider to
report the error. The health care provider 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
Co
orrrec
ct!
Telling the health care provider that the error warrants the
completion of an incident report
Telling the nursing supervisor that the health care provider did not
want an incident report completed and filed
Rationale: Incident reports are an important part of a
health care agency’s quality improvement program. An
incident is any event that is not consistent with the routine
operation of a health care 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 health care provider 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 health care provider’s telling the nurse that
an incident report is not needed. Eliminate the comparable
or alike options that 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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 3
, Contact precautions are initiated for a client with methicillin-
resistant Staphylococcus aureus (MRSA) infection. The nurse,
providing instructions to a nursing assistant about caring for the
client, tells the assistant to take which action?
To transfer the client to a semiprivate room
That gloves only are needed to care for the client
Co
orrrec
ct!
To wear gloves and a gown when changing the client’s bed linen
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.
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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Question 4
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.
Co
orrrec
ct!
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.
, Rationale: An incident is any event that is not consistent
with the routine operation of a health care 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 knowledge of the subject,
reasons for filing an incident report, to assist you with the
process of elimination. Read each option carefully.
Recalling that an incident is any event that is not
consistent with the routine operation of a health care 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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 2
A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that
atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse
checks the client’s vital signs, completes an incident report,and calls the health care provider to
report the error. The health care provider 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
Co
orrrec
ct!
Telling the health care provider that the error warrants the
completion of an incident report
Telling the nursing supervisor that the health care provider did not
want an incident report completed and filed
Rationale: Incident reports are an important part of a
health care agency’s quality improvement program. An
incident is any event that is not consistent with the routine
operation of a health care 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 health care provider 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 health care provider’s telling the nurse that
an incident report is not needed. Eliminate the comparable
or alike options that 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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 3
, Contact precautions are initiated for a client with methicillin-
resistant Staphylococcus aureus (MRSA) infection. The nurse,
providing instructions to a nursing assistant about caring for the
client, tells the assistant to take which action?
To transfer the client to a semiprivate room
That gloves only are needed to care for the client
Co
orrrec
ct!
To wear gloves and a gown when changing the client’s bed linen
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.
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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Question 4
