A nurse is preparing to participate in a root cause analysis after a sentinel event involving a surgical procedure performed on the wrong site. Which nursing action is the most appropriate to prevent this type of sentinel event from recurring?

Rationale:
A. Discussing palliative care options and symptom management is correct because it aligns with the goals of care for a client with a DNI order. The nurse should provide support, education, and interventions focused on comfort, alleviating distressing symptoms, and respecting the client’s wishes.

B. Providing chest compressions and defibrillation is incorrect if the client has a code status that limits resuscitation efforts. A DNI order typically applies to intubation, but many clients also specify “Do Not Resuscitate” (DNR); the nurse must clarify the client’s preferences regarding CPR. Blindly performing compressions may violate the client’s wishes.

C. Preparing for endotracheal intubation is incorrect because the client has a DNI order. Intubation is explicitly prohibited, and preparing for it would contradict the client’s legally documented directive.

D. Administering medications such as epinephrine during resuscitation is incorrect unless the client’s code status allows certain interventions. The nurse must follow the limits specified in the code status.

E. Administering oxygen therapy via nasal cannula is correct because it is a non-invasive measure to support oxygenation and relieve respiratory distress. It does not violate a DNI order and is consistent with comfort-focused care.

F. Using non-invasive ventilation without client consent is incorrect because any intervention that significantly impacts breathing requires the client’s agreement, especially if it could be uncomfortable or invasive. Respecting autonomy is essential.

G. Withholding all forms of CPR, including chest compressions, is incorrect unless the client has a documented DNR order in addition to the DNI. DNI specifically restricts intubation, not necessarily other resuscitation measures, so blanket withholding could misinterpret the client’s wishes.

Rationale:
A. Scanning the bar code on the medication administration record (MAR) and the client’s armband is correct practice. This is part of barcode-assisted medication administration (BCMA), which helps ensure the “five rights” of medication administration: right patient, right drug, right dose, right route, and right time.

B. Documenting medication administration prior to giving the medication is incorrect and requires intervention because it can lead to medication errors and falsification of records. Accurate documentation should always occur after the medication is administered to ensure the record reflects what was actually given and to maintain patient safety. Pre-documentation creates a risk of missing errors, skipped doses, or giving the wrong medication.

C. Checking the provider's orders and confirming the dosage in a medication reference guide is correct because it demonstrates due diligence in verifying medication safety and dosage accuracy before administration.

D. Verifying the medication against the prescription and medication label is correct as it ensures accuracy in medication delivery, preventing errors such as administering the wrong drug or incorrect dose.