A nurse is caring for a client and preparing to complete a medication reconciliation. Which of the following actions should the nurse complete first?

A) A client receives their meal tray 20 minutes late: While it's not ideal for a client to receive their meal late, this situation does not typically require an incident report unless there are extenuating circumstances or if the delay significantly impacts the client's health or well-being. However, it's important to document the delay in the client's chart for accurate record-keeping and to ensure appropriate follow-up.

B) A client vomits after receiving an oral medication: This situation may warrant an incident report. Vomiting after receiving medication could indicate a potential adverse reaction or intolerance to the medication. An incident report would document the event, including details such as the medication administered, the time of administration, the client's response, and any subsequent interventions. This information is crucial for identifying trends, ensuring proper follow-up care, and preventing similar incidents in the future.

C) A client experiences a seizure: Seizures are significant events that typically require immediate attention and intervention. While an incident report may be initiated after the seizure episode, the priority is to ensure the client's safety and provide appropriate medical care during and after the seizure. The focus should be on assessing the client, implementing seizure precautions if necessary, and administering any prescribed rescue medications or treatments as indicated.

D) A client receives their insulin 1 hour before scheduled: Administering insulin an hour before the scheduled time could potentially lead to hypoglycemia or other adverse effects, especially if the client's mealtime or activity level does not align with the earlier administration time. This situation may require an incident report to document the deviation from the prescribed schedule, assess the client's blood glucose levels, and determine if any corrective actions or additional monitoring are necessary.

A) "Why don't you want to take this injection?":
While it's important to understand the client's concerns, this response may come across as confrontational or dismissive. It's essential to respect the client's autonomy and decision-making process without immediately questioning their choice.

B) "You should trust your provider and receive the injection.":
This response is not respectful of the client's autonomy and decision-making. It disregards the client's right to refuse treatment and may further erode trust between the client and the healthcare team.

C) "I agree it is not something you want, but it will benefit you.":
This response is dismissive of the client's decision and fails to respect their autonomy. It's important to acknowledge the client's right to refuse treatment and provide support rather than attempting to persuade or coerce them into accepting it.

D) "I will inform your provider about your decision.":
This response respects the client's autonomy and ensures that the healthcare provider is aware of the client's decision. It allows for further discussion between the client and the provider to address any concerns or questions the client may have.