a nurse is preparing to complete an incident report regarding a medication error which of the following actions should the nurse plan to take
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Leadership and Management HESI Quizlet

1. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take?

Correct answer: B

Rationale: The correct answer is to identify the medication name and dosage administered to the client in the incident report. This information is crucial for accurate documentation and investigation of the medication error. Choice A is incorrect because incident reports are usually kept confidential and not for personal keeping. Choice C is incorrect as obtaining an order from the client's provider is not necessary to complete an incident report. Choice D, while important, is not the only essential information needed for the incident report.

2. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?

Correct answer: B

Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.

3. A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct answer: D

Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.

4. Select the stage of shock that is accurately paired with its characteristic.

Correct answer: C

Rationale: The progressive stage of shock is accurately described as the stage where histamine is released, leading to fluid and proteins leaking into surrounding tissues and the blood thickening. In this stage, the body's compensatory mechanisms are overwhelmed, resulting in a cascade of events that worsen the shock state. Choice A is incorrect as hyperventilation and a rise in blood pH are more characteristic of the compensatory stage. Choice B is incorrect as hypoxia and a rise in lactic acid are more typical of the progressive stage. Choice D is incorrect as the described electrolyte imbalances and metabolic acidosis are more aligned with the refractory stage of shock.

5. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

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