A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

The name of the provider who prescribed the medication

The time the client was to receive the medication

The date of the Incident

The client's vital signs

The potential adverse effects of the medication

Answer and Explanation

Correct Answer : B,C,D

Rationale:

A. The name of the provider who prescribed the medication is not necessary for the variance report; focus should be on the incident itself.

B. The time the client was to receive the medication should be included to document the discrepancy accurately.

C. The date of the incident is essential for accurate record-keeping and follow-up.

D. The client's vital signs such as blood pressure are especially relevant for medications like furosemide, which affects fluid balance and blood pressure. These values help assess for harm or trends following the missed dose.

E. The potential adverse effects of the medication are not typically included in the incident report but might be noted in the client's ongoing care plan.

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Correct Answer is B

Explanation

Rationale:

A. Applying restraints to prevent an alert, oriented client from leaving AMA: This is an example of false imprisonment, not negligence.

B. Negligence is the failure to act as a reasonably prudent nurse would under similar circumstances. Notifying the provider hours after discovering absent peripheral pulses shows a delay in appropriate action, which can lead to serious complications (e.g., compartment syndrome, tissue ischemia). This failure to act promptly meets the definition of negligence.

C. Administering medication without the client’s knowledge after refusal: This constitutes battery, as it involves intentional, unauthorized physical contact.

D. Threatening to apply restraints if the client continues eating chips: This is assault, since it is a threat of harm without physical contact.

A. Inform the staff member of her appraisal time for that day prior to change-of-shift report. B. Schedule the appraisal interview as early in the shift as possible. C. Provide the staff member with a copy of the appraisal form in advance. D. Provide a chair directly across the desk for the staff member to sit in.

Correct Answer is C

Explanation

Rationale:

A. Informing the staff member of her appraisal time for that day prior to change-of-shift report is not ideal as it may disrupt the shift handover process.

B. Scheduling the appraisal interview as early in the shift as possible might not be feasible or considerate, especially if it impacts patient care or the staff member's workflow.

C. Providing the staff member with a copy of the appraisal form in advance is best practice as it allows the staff member to prepare for the discussion and address any concerns or achievements.

D. Providing a chair directly across the desk for the staff member to sit in is not as important as preparing the staff member by sharing the appraisal criteria in advance.

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A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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