A charge nurse is concerned about a recent increase in facility-acquired catheter infections.

Which of the following actions should the nurse take first?

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.

The correct answer is Choice A.

Choice A rationale:

• Acknowledges the client's feelings:It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
• Provides information about the treatment:The nurse can offer information about the potential benefits of ECT,but it's important not to pressure the client or make them feel like they have to go through with it.
• Reassures the client of their right to change their mind:This is a crucial aspect of informed consent.The client has the right to withdraw their consent at any time,even after signing the consent form.

Choice B rationale:

• Places undue pressure on the client:This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts.This can undermine the client's autonomy and decision-making ability.

Choice C rationale:

• May minimize the client's concerns:While rescheduling the treatment is an option,it's important to explore the client's concerns more thoroughly before suggesting this.It's possible that the client has valid reasons for not wanting to go through with ECT,and these reasons should be addressed.

Choice D rationale:

• Is disrespectful of the client's autonomy:This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form.This ignores the fact that people can change their minds and that consent is an ongoing process.