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 A

Explanation

Rationale:

A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.

B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.

C.The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).

D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.

A. Defamation of character B. Slander C. False imprisonment D. Invasion of privacy

Correct Answer is C

Explanation

Rationale:

A. Defamation of character involves damaging someone’s reputation, which is not relevant in this context.

B. Slander involves spoken defamation, not applicable here.

C. False imprisonment refers to the unlawful restraint or restriction of an individual’s freedom, which can occur with unauthorized use of restraints.

D. Invasion of privacy involves unauthorized access to personal information or space, not directly related to the use of restraints.

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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

A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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