A nurse manger is reviewing the medication administration records on 6 clients.
Which of the following client situations require an incident report? Select all that apply.
Client 1
Client 2
Client 4
Client 3
Client 5
Client 6
Correct Answer : B,C,D,E
A. Client 1:
Cefaclor was scheduled for 0800 and given at 0830 - this is a 30-minute delay, which is generally acceptable unless the medication is time-critical (e.g., insulin, antibiotics for sepsis). Since antibiotics should be given on time, but a 30-min delay is within the acceptable window, this does not require an incident report.
B. Client 2:
The client vomited undigested food and medication 30 minutes after administration. This is a medication effectiveness concern that should be documented and reported because the dose may need to be repeated, and the provider must be notified. An incident report is appropriate.
C. Client 4:
Furosemide was prescribed PO but administered IV at 1400. This is a route error, which is a medication administration error requiring an incident report.
D. Client 3:
Warfarin was administered despite an INR of 3.8 (above the hold parameter of >3.5). This is a clear medication error with potential for harm, requiring an incident report.
E. Client 5:
Gentamicin dose was prescribed at 150 mg IM, but 300 mg IM was given - this is a double dose and a serious medication error requiring immediate incident reporting.
F. Client 6:
Atenolol was appropriately held only if apical pulse <60/min; pulse was 62/min, so administration was within parameters - no error here.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A. Nurses' notes:
Nurses’ notes are part of the ongoing hospital documentation but are not typically sent as a primary record for home health agencies; they need essential care continuity details.
B. Current medications:
The home health agency must have an up-to-date medication list to ensure continuity of care and safe administration at home.
C. Nursing admission assessment:
The admission assessment provides baseline hospital data but is less critical for immediate home care than the current treatment plan and medications.
D. Vital signs flow sheet:
While helpful, a vital signs record is not the primary document needed for discharge coordination; current status and treatment plans take priority.
Correct Answer is C
Explanation
A. Admission paperwork:
Admission paperwork is not essential for emergency transfer; it contains historical data that is less urgent for immediate care decisions.
B. Care plan:
While the care plan outlines ongoing interventions, it is less critical for emergency management during an acute event.
C. Medication administration record:
The MAR provides essential, up-to-date information about the client’s current medications, dosages, and administration times, which is critical for safe and accurate care in the receiving facility.
D. Discharge summary:
A discharge summary is completed at the end of a stay, not during an emergency transfer.
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