A nurse is preparing to report a medication error to the nurse manager.

What is the most appropriate action for the nurse to take?

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

Notify the client's physician and the risk management department.

Explain the error to the client and apologize sincerely.

Wait until the end of the shift to report the error.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is D

Explanation

All of the above

Rationale: The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.

Incorrect options:

A) The type and amount of dressing used - This is an important information to document, but not the only one.

B) The location and size of the wound - This is an important information to document, but not the only one.

C) The appearance and odor of the wound - This is an important information to document, but not the only one.

A. An air leak in the system B. A normal functioning of the system C. A need to empty the collection chamber D. A need to clamp the chest tube

Correct Answer is A

Explanation

An air leak in the system

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can compromise the negative pressure needed for effective drainage of air and fluid from the pleural space. The nurse should locate the source of the air leak and take appropriate measures to correct it. Possible sources of air leak include loose connections, cracks or holes in the tubing or drainage container, or a leak in the lung tissue.

Incorrect options:

B) A normal functioning of the system - Intermittent bubbling in the water seal chamber during inspiration, expiration, or coughing is a normal finding that indicates that air is being removed from the pleural space. Continuous bubbling is abnormal and indicates an air leak.

C) A need to empty the collection chamber - The collection chamber is where fluid drained from the pleural space accumulates. The nurse should empty the collection chamber when it is full or according to facility policy. Bubbling in the collection chamber is not a normal finding and does not indicate a need to empty it.

D) A need to clamp the chest tube - Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.

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A nurse is preparing to report a medication error to the nurse manager. What is the most appropriate action for the nurse to take?

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A nurse is preparing to report a medication error to the nurse manager.

What is the most appropriate action for the nurse to take?