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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Stopping feeding for a client who becomes short of breath demonstrates clinical judgment rather than fidelity. Fidelity specifically involves loyalty and adherence to commitments made to the client, which is not evidenced in this action.
Choice B rationale
Telling a client she will return with a medication and doing so exemplifies fidelity. It demonstrates the nurse's reliability and dedication to fulfilling promises or commitments made to the client, building trust and maintaining professional integrity.
Choice C rationale
Dividing time and care evenly between clients highlights fairness rather than fidelity. While fairness ensures equal treatment, fidelity focuses on maintaining trust and honoring specific promises or commitments made to individuals.
Choice D rationale
Administering a pain medication to a client before ambulation reflects prioritization of care and pain management. However, it does not illustrate fidelity, which involves fulfilling promises or responsibilities that the nurse has explicitly committed to.
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.
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