A nurse is assisting with the discharge of a client from acute care to home health care. Which of the following components of the medical record should the nurse provide to the home health agency?

A) Sublingual medication is crushed and administered through a client's gastrostomy tube: This scenario represents a violation of the client's right to refuse treatment or medication. Administering medication through a route other than the one prescribed without the client's consent is inappropriate and can result in harm or adverse effects.

B) Finger nail marks appear on a client's wrist after a radial pulse was taken: This scenario indicates a violation of the client's right to be free from abuse. Evidence of physical harm, such as finger nail marks, suggests that the client may have been handled roughly or experienced unnecessary force during the procedure, which is unacceptable.

C) Pain medication is administered 1 hr before a client has a dressing change: While administering pain medication slightly ahead of a painful procedure may be appropriate to provide optimal pain relief, it does not inherently violate the client's rights if it aligns with the client's pain management plan and preferences. Therefore, this scenario does not represent a clear violation of client rights.

D) The same indwelling urinary catheter is reinserted after a failed attempt: Reinserting the same urinary catheter after a failed attempt could represent a violation of the client's right to safe care and freedom from unnecessary discomfort. Repeated attempts at catheter insertion without clinical justification increase the risk of infection and discomfort for the client.

E) Medications scheduled four times a day are administered 2 hr after the scheduled time: Administering medications significantly late violates the client's right to receive care in a timely manner. Delayed medication administration can affect treatment efficacy and compromise the client's well-being, especially for medications with strict dosing schedules.

A) Contact the nurse from the previous shift to report the doubled dose:

While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.

B) Document the doubled dose in the client's medical record:

Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.

C) Place a copy of the incident report in the client's record:

While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.

D) Report the incident to the manager of the pharmacy:

Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.