During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?
Telephone the nurse responsible for the error at home to report the omission of the transcription.
Call the healthcare provider and ask if the prescription is still needed since 12 hours have elapsed since it was written.
Notify the nursing supervisor of the previous shift's omission in not transcribing the prescription.
Order the lab work as prescribed and follow procedures for completing an incident report.
The Correct Answer is D
Choice A rationale: This option involves contacting the nurse at home, which may not be appropriate or effective for addressing the immediate issue of the transcription omission.
Choice B rationale: Contacting the healthcare provider is important, but the nurse should first order the lab work as prescribed and complete and incident report.
Choice C rationale: Notifying the nursing supervisor of the previous shift's omission is important but the nurse should first order the lab work as prescribed.
Choice D rationale: Ordering the lab work as prescribed and following procedures for completing an incident report is the best action for the nurse to take because it ensures that the client's serum potassium levels are monitored and that the error is documented and reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.
Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.
Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica
Correct Answer is C
Explanation
Choice A rationale: Asking the nurse to explain thoughts on the need for an in-service program encourages open communication and allows the nurse-manager to address specific concerns.
Choice B rationale: Choosing to send another nurse may not address the concerns of the nurse expressing dissatisfaction and may not promote a collaborative approach. Choice C rationale: Encouraging the nurse to share concerns and discuss ways to prepare for emergencies fosters open communication and allows for constructive dialogue.
Choice D rationale: Informing the nurse that in-service is not optional and attendance is mandatory may create resistance and does not promote a collaborative approach to addressing concerns.
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