A nurse is preparing to administer a medication to a client and discovers that the incorrect dose of medication was administered during the previous shift. Which of the following actions should the nurse take first?

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.