A nurse is admitting an adolescent who has rubella.

Which of the following actions should the nurse take?

Choice A reason:

Completing an incident report is not the correct action. An incident report should be completed as part of the hospital's protocol to document the medication error and ensure appropriate follow-up and investigation.

Choice B reason:

Checking the client for indications of bleeding is the correct action to be taken. In this situation, the nurse's first priority should be to assess the client for indications of bleeding, as the client received a significantly higher dose of IV heparin than prescribed. Heparin is an anticoagulant medication used to prevent blood clots, and an overdose can increase the risk of bleeding.

After administering the wrong dose of medication, the nurse's immediate concern is the client's safety and well-being. Checking for signs of bleeding, such as petechiae, ecchymosis, hematomas, bleeding gums, melena (black, tarry stools), haematuria (blood in urine), or any other unusual bleeding, is crucial.

Choice C reason:

Monitor the client's aPTT levels: This is not the correct action to be taken. Monitoring the client's activated partial thromboplastin time (aPTT) levels is essential to assess the client's coagulation status and determine if the overdose of heparin has affected their clotting ability. The healthcare provider may adjust the heparin dosage based on the aPTT levels.

Choice D reason:

Notify the risk manager: This is not the correct action to be taken. The risk manager or appropriate supervisor should be informed about the medication error as soon as possible to initiate a thorough review of the incident and take necessary steps to prevent similar errors in the future.

The correct answer is: B

Choice A reason: A social worker may assist clients in many ways, including finding legal representation. However, this statement does not address the client’s concern about the cost of legal representation for advance directives. It’s important to note that while social workers can provide support, they do not eliminate the need for legal representation if the client chooses to seek it.

Choice B reason: This is the correct statement because advance directives do not require legal representation to be valid. They become legally binding when signed in front of the required witnesses. This option directly addresses the client’s concern about affording legal representation by informing them that it is not necessary for the creation of advance directives.

Choice C reason: While medical care can be initiated without advance directives, this statement does not address the client’s concern about the cost of creating advance directives. It also implies that medical care is contingent on the completion of legal documents, which is not accurate.

Choice D reason: Verbal agreements are not as legally binding as written advance directives and could lead to misunderstandings or disputes later on. It is important for the client to have a clear and documented advance directive, which does not necessarily require legal review to be valid.