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?

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

Report the incident to the manager of the pharmacy.

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

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

Answer and Explanation

The Correct Answer is A

Choice A rationale

Documenting the doubled dose in the medical record ensures transparency and provides critical information for continuity of care. Accurate documentation allows the healthcare team to monitor the client for potential adverse effects, supporting accountability and preventing recurrence of medication errors.

Choice B rationale

Reporting the incident to the pharmacy manager addresses systemic issues, such as procedural errors or staff education needs, to prevent similar occurrences. However, this action does not directly prioritize client safety or care in response to the doubled dose.

Choice C rationale

Placing a copy of the incident report in the client’s record breaches confidentiality and violates facility policy. Incident reports are administrative tools to address safety concerns, not a part of the client’s medical record.

Choice D rationale

Contacting the nurse from the previous shift might provide insight into the error’s cause but does not address the immediate need to ensure client safety or document the error. This step is secondary to accurate record-keeping and reporting.

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Correct Answer is D

Explanation

Choice A rationale

Completing an incident report is important for documentation and accountability but does not address the immediate issue of a fainting family member. Ensuring the family member's safety takes precedence in this scenario.

Choice B rationale

Notifying the nurse manager is necessary for communication, but it is not the first action. Prioritizing assessment ensures any critical issues are promptly addressed to stabilize the family member's condition.

Choice C rationale

Obtaining the family member’s health history could provide context for the fainting episode but delays immediate assessment. Addressing acute concerns like airway, breathing, and circulation is crucial before obtaining history.

Choice D rationale

Checking vital signs is a priority as it provides immediate information about the family member’s condition. Assessment of blood pressure, heart rate, and oxygen saturation helps identify underlying causes such as hypotension, arrhythmia, or hypoxia for appropriate intervention.

A. A provider who suspects partner violence asks to speak with the client alone. B. A client requests that a nurse provide information by telephone to their partner. C. A dietitian prescribes a kosher meal tray for a client who practices the Orthodox Jewish faith. D. A nurse does not provide an interpreter for a client who speaks a different language than the nurse.

Correct Answer is D

Explanation

Choice A rationale

Asking to speak privately with a client suspected of experiencing partner violence is appropriate. It ensures confidentiality and creates a safe environment for the client to disclose sensitive information, aligning with legal and ethical practices.

Choice B rationale

Sharing information with a client’s partner over the phone requires patient authorization due to confidentiality under HIPAA regulations. While concerning, legal violations occur only if the nurse acts without explicit consent.

Choice C rationale

A dietitian prescribing a kosher meal for a client observing Orthodox Jewish dietary laws respects cultural and religious preferences, supporting patient-centered care without any legal implications.

Choice D rationale

Failure to provide an interpreter for a client who speaks a different language is a potential legal issue. It violates the patient’s right to effective communication under federal laws like the Americans with Disabilities Act (ADA) and Title VI of the Civil Rights Act.

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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?

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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?