A nurse is documenting the wound care provided to a client who has a pressure ulcer on the sacrum.

Which information should the nurse include in the documentation?

To prevent lactic acidosis due to contrast dye

Rationale: Metformin is an oral antidiabetic agent that lowers blood glucose levels by decreasing hepatic glucose production and increasing peripheral glucose uptake. However, metformin can cause lactic acidosis, a rare but serious condition that occurs when lactate accumulates in the blood faster than it can be metabolized. Lactic acidosis can be triggered by contrast dye used for radiographic procedures, such as colonoscopy, especially in clients who have renal impairment or dehydration. Therefore, metformin should be discontinued 48 hours before and after any procedure that involves contrast dye.

Incorrect options:

A) To prevent hypoglycemia during fasting - This is not the rationale for discontinuing metformin, as metformin does not cause hypoglycemia by itself. However, the client may need to adjust the dose of other antidiabetic medications or insulin to prevent hypoglycemia during fasting.

C) To prevent hyperglycemia due to stress response - This is not the rationale for discontinuing metformin, as metformin does not cause hyperglycemia by itself. However, the client may need to monitor blood glucose levels more frequently and report any signs of hyperglycemia to the provider.

D) To prevent nephrotoxicity due to dehydration - This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.

Document the error in the client's medical record and the incident report.

Rationale: The nurse should document the error in both the client's medical record and the incident report, as this is part of the legal and ethical responsibility of the nurse. The documentation should include the facts of what happened, what actions were taken, and the client's response.

Incorrect options:

B) Notify the client's physician and the risk management department. - This is not the most appropriate action, as the nurse should first report the error to the nurse manager, who will then decide who else needs to be notified and how to proceed with further investigation and follow-up.

C) Explain the error to the client and apologize sincerely. - This is not the most appropriate action, as the nurse should first ensure that the client is safe and stable, and then consult with the nurse manager and the legal department before disclosing the error to the client. The nurse should also avoid admitting fault or liability, as this could have legal implications.

D) Wait until the end of the shift to report the error. - This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.