A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?
Request a medication reconciliation form from the pharmacy.
Ask the client if she received the 1700 medication.
Contact the previous nurse to determine if the client received the medication.
Administer the medication and document the current time.
The Correct Answer is C
Choice A Reason:
Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.
Choice B Reason:
Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.
Choice C Reason:
Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.
It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.
Choice D Reason:
Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.
Choice B Reason:
To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.
Choice C Reason:
To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.
Choice D Reason:
To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.
Correct Answer is D
Explanation
Choice A Reason:
Lowering the side rail on the side of the bed where the AP will stand to perform mouth care is a safety measure. It provides better access to the client and allows the AP to perform the task more comfortably and effectively. This action helps prevent the AP from leaning over an elevated side rail, reducing the risk of injury to themselves or the client.
Choice B Reason:
Wearing clean gloves to perform mouth care for the client is a safety measure. Wearing gloves is crucial to maintain hygiene and prevent the transmission of microorganisms during mouth care.
Choice C Reason:
Using an oral care sponge swab moistened with cool water to clean the client's mouth is a safety measure. Using a moistened oral care sponge swab is a suitable method for providing mouth care to an unconscious client, helping to keep the mouth clean and moist.
Choice D Reason:
Using two gloved fingers to open the client's mouth for cleaning is NOT a safety measure. In this situation, using fingers to open the client's mouth poses a risk of injury or discomfort to the client. It's important to handle an unconscious patient's mouth with care and avoid using fingers to open the mouth forcibly.
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