The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?

Choice A reason: Calling the provider is important, but it is not the immediate priority. Before contacting the provider, the nurse needs to assess the client's condition to provide accurate information about any potential adverse effects of the medication error.

Choice B reason: Notifying risk management is a necessary step in reporting the medication error, but it should be done after ensuring the client's safety and stability. Immediate patient assessment takes precedence.

Choice C reason: Checking the client's vital signs is the priority action because it allows the nurse to assess the client's current condition and identify any immediate adverse effects of the medication error. This information is critical for determining the appropriate next steps and ensuring the client's safety.

Choice D reason: Completing an incident report is essential for documenting the medication error, but it should be done after addressing the client's immediate needs and ensuring their safety. The nurse's first responsibility is to assess and manage the client's condition.

Choice A reason: The statement "The client fell out of bed" is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions. Therefore, this statement should not be included in the incident report.

Choice B reason: Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.

Choice C reason: Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.

Choice D reason: The statement "The client apparently climbed over the side rails unwitnessed" includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.

Choice E reason: Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.