A mother called the pediatrician's office, reporting that her infant son had a temperature of 102.6

F. The nurse is to record the information as a Celsius temperature.

What should the nurse write down as the temperature reported by the mother?

Choice A rationale

Administering medication without verifying the order, especially when the patient expresses concern about a change in appearance, is a breach of medication safety principles. The patient's concern highlights a potential discrepancy, and simply explaining a possible change without confirmation is unprofessional and dangerous.

Choice B rationale

This action is incorrect and dangerous. The patient stated she always takes a yellow pill, but the nurse is preparing to administer a blue tablet. Telling her the action of a "red tablet" is confusing, indicates a potential misunderstanding of the medication, and demonstrates a failure to address the patient's valid concern about the color discrepancy.

Choice C rationale

When a patient questions a medication, especially regarding its appearance, it is imperative to withhold the drug and recheck the medication administration record (MAR) against the physician's original order. This verifies that the correct medication, dose, and form are being administered, preventing potential medication errors and ensuring patient safety.

Choice D rationale

Administering the medication and making a mental note to check later is unsafe practice. A patient's concern about medication is a critical alert. Ignoring it and administering the drug first could lead to serious adverse effects if a medication error has occurred. Verification must precede administration.

Choice A rationale

Delayed documentation increases the risk of medication errors, as details about administration, patient response, and specific timing can be forgotten or inaccurately recalled, compromising patient safety and the accuracy of the medical record.

Choice B rationale

Nurses are legally and professionally obligated to document medications they personally administer. Documentation by a pharmacy technician is inappropriate and violates the principle of direct accountability for medication administration.

Choice C rationale

Only the individual who directly administers the medication should document its administration. This ensures accuracy, accountability, and traceability of the medication process, preventing errors and maintaining legal integrity of the medical record.

Choice D rationale

Immediate documentation after medication administration is a critical safety principle. It accurately reflects the precise time of administration, allowing for timely assessment of patient response, identification of adverse effects, and continuity of care.