A nurse is preparing to administer a measles, mumps, and rubella (MMR) immunization. Which of the following client characteristics is a contraindication to administration?

Rationale:

A. A nurse finds medication on the client’s bedside table upon entering the room: While this is a safety concern, it may not necessarily require an incident report unless it resulted in harm or was due to a medication error. It should be documented and investigated, but may not meet the threshold for a formal report depending on facility policy.

B. A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500: This represents a medication administration error—giving the drug significantly earlier than prescribed. Administering time-sensitive medications outside the scheduled time can affect patient safety and should be reported using an incident report for evaluation and prevention.

C. A client's MAR indicates the 0800 dose of morphine was withheld because the client refused to take the medication: Client refusal of medication is not an error and does not require an incident report. It should be documented in the medical record along with any related assessments or follow-up, but it is not a reportable incident.

D. A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the client’s bedside: This situation suggests a delay in removing the IV bag, which is a minor deviation from ideal practice but typically does not require an incident report unless there was harm, contamination, or risk of adverse outcome.

Rationale:

A. Speech pathologist: A speech pathologist evaluates and treats dysphagia (difficulty swallowing) and communication impairments following a stroke. This referral is essential to assess swallowing safety and prevent aspiration.

B. Respiratory therapist: A respiratory therapist assists with pulmonary care, oxygen therapy, or ventilatory support. Unless the client has respiratory complications, a referral is not typically indicated solely for stroke-related weakness or swallowing difficulty.

C. Occupational therapist: An occupational therapist helps the client regain the ability to perform daily activities (e.g., dressing, grooming) that may be impaired by right-sided weakness. This referral supports independence and rehabilitation.

D. Physical therapist: A physical therapist works to improve mobility, balance, and strength in clients with musculoskeletal impairments after a stroke. Right-sided weakness makes this referral highly appropriate for motor recovery.

E. Pharmacist: A pharmacist ensures appropriate medication management, but a direct referral is not typically required for stroke rehabilitation unless there are specific medication concerns or complexities.