A nurse witnesses a newly licensed nurse take a client's prescribed pain medication instead of administering it to the client. Which of the following actions should the nurse take?
Instruct the newly licensed nurse to complete an incident report.
Document the incident in the client's medical record.
Provide the client with information about the incident.
Communicate the incident to the nurse manager.
The Correct Answer is D
A. While completing an incident report is important for documenting the event, the witness should not instruct the newly licensed nurse to do so. Instead, it is the responsibility of the observer (the witness nurse) to report the incident to the appropriate authority to ensure that it is addressed properly.
B. Documenting the incident in the client's medical record is not appropriate in this case. The client’s medical record should only contain information relevant to the client’s care and treatment, not details about medication errors or policy violations.
C. While transparency is important, directly informing the client about a medication error is not typically the responsibility of the witnessing nurse. The primary focus should be on addressing the immediate issue and ensuring it is reported to the appropriate authorities rather than discussing the incident with the client.
D. The nurse manager is responsible for overseeing the unit and addressing incidents such as medication errors. Reporting the incident to the nurse manager ensures that it is investigated according to facility protocols.
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Related Questions
Correct Answer is D
Explanation
A. This is primarily the provider's responsibility. The nurse can support the provider by providing information about the procedure and alternative options if requested.
B. While the nurse can provide general information about the procedure, the provider is typically responsible for discussing the specific risks and benefits with the client.
C. This is the responsibility of the medical records department or the provider's office staff. The nurse may be involved in ensuring that the original signed consent is obtained and properly documented.
D. The nurse's role is to verify that the client fully understands the procedure and has given informed consent. This involves assessing the client's comprehension of the information provided by the provider. If the client has any questions or concerns after the provider's explanation, the nurse can clarify them to ensure complete understanding.
Correct Answer is C
Explanation
A. Airborne precautions are necessary for preventing the spread of pathogens that are transmitted through tiny airborne droplets, which can remain suspended in the air and travel over longer distances than 3 feet. For clients requiring airborne precautions, such as those with tuberculosis, measles, or varicella, an N95 respirator mask or higher-level protection is required regardless of distance from the client.
B. Influenza is primarily spread through droplet transmission, not airborne transmission. For clients with influenza, droplet precautions are appropriate, which include wearing a surgical mask and practicing good hand hygiene.
C. Measles is transmitted via airborne particles. Therefore, an N95 respirator mask is required when caring for a client with measles to protect against airborne transmission. Airborne precautions, including the use of N95 respirators, are crucial for preventing the spread of measles and other airborne diseases such as tuberculosis.
D. Clients with varicella (chickenpox) require airborne precautions because the varicella virus can spread through airborne particles. However, varicella-infected clients should be placed in a negative pressure room, not a positive pressure room.
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