A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

Contact the nurse from the previous shift to report the doubled dose.

Document the doubled dose in the client's medical record.

Place a copy of the incident report in the client's record.

Report the incident to the manager of the pharmacy.

Answer and Explanation

The Correct Answer is B

A) Contact the nurse from the previous shift to report the doubled dose:

While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.

B) Document the doubled dose in the client's medical record:

Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.

C) Place a copy of the incident report in the client's record:

While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.

D) Report the incident to the manager of the pharmacy:

Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.

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Correct Answer is C

Explanation

A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.

B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.

C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.

D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.

A. Soft-serve ice cream B. Hot tea C. String cheese D. Raisin toast

Correct Answer is D

Explanation

Answer: D. Raisin toast

Rationale:

A. Soft-serve ice cream:
While soft-serve ice cream may seem appealing due to its mild taste and smooth texture, it can be high in sugar and fat, which might not be well-tolerated by patients experiencing chemotherapy-induced nausea. Heavy or rich foods can exacerbate nausea, making them less suitable for these clients.

B. Hot tea:
Hot tea can be soothing, but for individuals experiencing nausea, the warmth might not be well-received. Additionally, certain teas can contain caffeine, which may not be advisable for those undergoing chemotherapy, as it can sometimes exacerbate dehydration or jitters.

C. String cheese:
String cheese is a dairy product that can be heavy for some patients, particularly those experiencing nausea from chemotherapy. Dairy may cause gastric discomfort, and many patients may prefer lighter, less greasy options when feeling nauseous.

D. Raisin toast:
Raisin toast is a suitable choice as it is light, easy to digest, and contains carbohydrates that can help settle the stomach. The raisins add some natural sweetness without being overly rich, making it a good option for someone experiencing chemotherapy-induced nausea. This selection demonstrates an understanding of dietary choices that may be better tolerated during episodes of nausea.

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A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

Rationale:

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