A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Choice A Reason:

A nurse discovers that a client's family member has administered a PCA dose: While this is a medication administration concern, it might not always require an incident report, but it should be addressed by the healthcare team to prevent future occurrences.

Choice B Reason:

A nurse observes a client vomiting after receiving an oral pain medication: This could be a medication reaction or a side effect, and it should be documented in the client's medical record, but it may not necessarily require a separate incident report.

Choice C Reason:

A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. Incident reports are typically used to document unexpected events or situations that deviate from the standard of care, and this includes situations where errors occur that could potentially harm the patient. In this case, the IV pump delivering twice the prescribed amount of fluid is a medication error that should be reported to document the occurrence and to ensure that corrective actions are taken to prevent similar incidents in the future.

Choice D Reason:

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: This might be a situation that requires clarification and discussion among the healthcare team, but it may not necessarily require an incident report unless there is concern about patient safety.

Choice A Reason:

Prolonged PT/INR (prothrombin time/international normalized ratio) is not typically seen in pancreatitis. It may be indicative of liver dysfunction or issues with blood clotting.

Choice B Reason:

Elevated lipase levels are commonly seen in clients with pancreatitis. Lipase is an enzyme produced by the pancreas, and when there is inflammation or damage to the pancreas, such as in pancreatitis, it can lead to the release of lipase into the bloodstream. Therefore, an elevated lipase level is a typical laboratory finding in clients with pancreatitis.

Choice C Reason:

Elevated ammonia levels are not typically associated with pancreatitis. Elevated ammonia levels may be seen in clients with liver disease or other metabolic disorders.

Choice D Reason:

Decreased albumin levels are not typically associated with pancreatitis. Decreased albumin levels may be seen in clients with liver disease or malnutrition, but it is not a specific marker for pancreatitis.