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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.

Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.

Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.

Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.

A. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis. B. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis. C. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED use D. Assign the PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for the new admission

Correct Answer is ["D"]

Explanation

- Choice A Rationale: This choice is not optimal because the PN has the skills necessary to assist with the thoracentesis, a procedure that requires clinical judgment and skill, which the UAP does not possess. The RN is also needed to obtain the report from the ED due to the complexity of unstable angina, which requires advanced knowledge and assessment skills.

- Choice B Rationale: This option incorrectly assigns the UAP to prepare the room, which is within their scope, but fails to utilize the PN's skills effectively. The PN should be involved in more complex tasks such as assisting with procedures or obtaining detailed reports, rather than the UAP.

- Choice C Rationale: This choice is inappropriate because it assigns the UAP to assist with the thoracentesis, a task they are not trained for and is outside their scope of practice. The RN should be involved in the more complex care of obtaining the report, and the PN should assist with the thoracentesis.

- Choice D Rationale: This is the correct choice because it utilizes all staff members according to their scope of practice and skills. The PN assists with the thoracentesis, a task they are qualified for, the RN obtains the report on the new admission, which requires advanced knowledge, and the UAP prepares the room, a task that fits their role.

- Choice E Rationale: As there is no Choice E provided in the question, no rationale can be given for this option. It is important to follow the instructions and options given in the scenario to provide accurate and relevant information.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is B

Explanation

Correct Answer is ["D"]

Explanation

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