A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Completion of the incident report
Time the medication was given
Reason for the medication error
Notification of the pharmacist
The Correct Answer is B
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag.
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
Correct Answer is C
Explanation
A. This choice is incorrect because the body temperature does not drop 1 degree 1 week after ovulation. The body temperature rises slightly (about 0.4 to 0.8 degrees Fahrenheit) after ovulation and remains elevated until the next menstrual period.
B. This choice is incorrect because the body temperature should be taken each morning before getting out of bed or doing any activity. Taking the temperature in the evening can result in inaccurate readings due to variations in daily activities, meals, stress, exercise, etc.
C. This choice is correct because the body temperature might decrease slightly (about 0.2 degrees Fahrenheit) just prior to ovulation due to a surge in estrogen levels. This dip in temperature can indicate that ovulation is about to occur and that the client should avoid unprotected intercourse if she wants to prevent pregnancy.
D. This choice is incorrect because the body temperature is not at its highest during menstruation. The body temperature drops at the onset of menstruation due to a decline in progesterone levels and marks the beginning of a new cycle.
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