A charge nurse is reviewing the medication administration records of six clients.

Exhibits
Which of the following client situations require an incident report? Select all that apply.

Client 2

Client 1

Client 3

Client 4

Client 5

Client 6

Answer and Explanation

Correct Answer : A,C,D,E

Rationale:
A. Client 2: The client vomited undigested food and medication shortly after administration, which may have prevented absorption and requires reporting.
B. Client 1: Cefaclor was administered 30 minutes late (0800 scheduled, given 0830), which is a minor timing discrepancy and does not require an incident report.
C. Client 3: Warfarin was administered despite an INR of 3.8, which is above the prescribed hold limit (>3.5), representing a medication error that requires an incident report.
D. Client 4: Furosemide was ordered PO but was administered IV, which is a route error and requires an incident report.
E. Client 5: Gentamicin was administered at 300 mg instead of the prescribed 150 mg, representing an overdose and requires an incident report.
F. Client 6: Atenolol was administered correctly per prescription, as the apical pulse was above the hold limit; no incident report is needed.

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Correct Answer is A

Explanation

Rationale:
A. A post-cesarean client with a PCA pump requires routine postoperative monitoring and pain management, which are familiar tasks for a medical-surgical RN. This makes the assignment appropriate.
B. A client with premature rupture of membranes at 32 weeks requires specialized obstetrical knowledge and monitoring for complications such as infection and preterm labor.
C. A client with preeclampsia on misoprostol induction requires close fetal and maternal monitoring, which demands specialized obstetric expertise.
D. A client with gestational diabetes undergoing nonstress tests needs interpretation of fetal monitoring results, which is outside the scope of practice for a floated med-surg RN.

A. Nonmaleficence B. Veracity C. Utility D. Autonomy

Correct Answer is A

Explanation

Rationale:
A. Nonmaleficence refers to the ethical principle of avoiding harm or preventing injury. By removing a fall hazard, the nurse is actively working to prevent harm to the client.
B. Veracity means telling the truth and being honest with clients, which is not demonstrated in this scenario.
C. Utility focuses on the greatest good for the greatest number, not on preventing individual harm in a direct care setting.
D. Autonomy is respecting the client’s right to make their own decisions about care, but it does not apply to removing environmental hazards.

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A charge nurse is reviewing the medication administration records of six clients. Exhibits Which of the following client situations require an incident report? Select all that apply.

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Explanation

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A charge nurse is reviewing the medication administration records of six clients.

Exhibits
Which of the following client situations require an incident report? Select all that apply.