A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?

Forward a completed incident report to the risk manager within 24 hr.

Notify the facility's pharmacist within 1 hr of the incident.

Call the nurse who made the error to discuss the medication error.

Place an incident report in the client's medical record.

Answer and Explanation

The Correct Answer is A

A. The nurse should complete an incident report and forward it to the risk manager within 24 hours as part of the facility’s protocol for reporting medication errors. This helps track errors, improve safety measures, and prevent future occurrences.
B. While a pharmacist may need to be involved in evaluating the error, there is no requirement to notify them within a specific timeframe. The priority is proper reporting and client monitoring.
C. Calling the nurse who made the error is not an appropriate action. Incident reports focus on improving systems rather than blaming individuals.
D. An incident report is not part of the medical record. It is an internal document used for quality improvement and risk management.

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Correct Answer is D

Explanation

A. Scant lochia rubra with a few small clots. Lochia rubra is expected in the early postpartum period, and small clots are normal unless excessive bleeding occurs.
B. Urine output 2,500 mL/day. Increased urine output is expected postpartum as the body eliminates excess fluid retained during pregnancy.
C. Bilateral ankle edema. Mild edema is common postpartum due to fluid shifts and typically resolves on its own.
D. 4+ deep-tendon reflexes. Hyperreflexia is a sign of central nervous system irritability and may indicate preeclampsia, which requires immediate evaluation.

A. Lubricate the catheter with water-soluble gel. B. Attach a prefilled syringe to the catheter inflation hub. C. Cleanse the client's meatus with antiseptic solution. D. Position the sterile drape leaving the perineum exposed.

Correct Answer is D

Explanation

A. Lubricating the catheter with water-soluble gel is important but is done after preparing the sterile field.
B. Attaching a prefilled syringe to the catheter inflation hub is performed after insertion to secure the catheter, not before.
C. Cleansing the client’s meatus with antiseptic solution is essential for infection prevention but is done after the sterile field is set up.
D. Positioning the sterile drape while leaving the perineum exposed is the first step because it maintains a sterile field and provides a clean working area for catheter insertion. This prevents contamination and reduces the risk of infection.

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A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?

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