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
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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Related Questions
Correct Answer is B
Explanation
Rationale:
A. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus requires a higher level of clinical judgment and is typically performed by an RN.
B. Assisting a client with crutch walking following knee replacement surgery is an appropriate task for an LPN, as it involves support with activities of daily living and mobility.
C. Evaluating the outcomes of a new postoperative client involves assessing the effectiveness of care and requires RN-level assessment skills.
D. Developing the plan of care for a client who has an amputation involves comprehensive assessment and planning, which is usually the responsibility of an RN.
Correct Answer is D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
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