The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which description(s) warrant additional follow-up by the nurse? (Select all that apply)

Choice A reason: High Fowler’s position aids breathing in respiratory distress but is not universally indicated without context. It may strain the client’s back or increase fatigue if sustained. Keeping mucous membranes moist is a broader intervention, preventing complications like oral infections or discomfort, especially in dehydrated or oxygen-dependent clients, making it more appropriate.

Choice B reason: Reporting changes in urine color monitors renal or hydration status but is less immediate than maintaining mucous membranes. Dry membranes risk infection or discomfort, particularly in clients on oxygen or with reduced oral intake. Urine monitoring is secondary, as it reflects longer-term changes rather than addressing an urgent physiological need.

Choice C reason: Keeping mucous membranes moist prevents drying, which can lead to infections, discomfort, or impaired swallowing. This is critical for clients on oxygen, with reduced intake, or in dry environments. Moist membranes support airway protection and comfort, aligning with nursing priorities to maintain basic physiological functions and prevent complications.

Choice D reason: Recording daily weight tracks fluid status or nutritional changes but is less urgent than moist mucous membranes. Dry membranes pose immediate risks like infection or airway irritation, especially in vulnerable clients. Weight monitoring is a longitudinal assessment, secondary to addressing acute comfort and infection prevention needs.

Choice A reason: Notifying the HCP immediately ensures prompt evaluation of the medication error’s impact and any needed interventions. Administering an unprescribed antibiotic risks adverse reactions or ineffective treatment. Prompt notification supports patient safety, aligns with error management protocols, and allows the HCP to adjust the care plan accordingly.

Choice B reason: Documenting in the EHR is critical but secondary to notifying the HCP. Immediate notification allows the provider to assess and mitigate harm from the unprescribed antibiotic. Documentation follows to record the error and actions taken, but delaying HCP contact risks prolonged exposure to potential adverse effects.

Choice C reason: Informing the next shift’s nurse ensures continuity but is not the priority. Notifying the HCP first addresses the immediate clinical implications of the unprescribed antibiotic. Shift reports are secondary, as the error requires prompt provider intervention to evaluate the client’s condition and prevent harm from the medication mistake.

Choice D reason: Completing an incident report is necessary for quality improvement but not the first step. Notifying the HCP ensures immediate clinical action to address the unprescribed antibiotic’s effects. Incident reports follow to analyze system issues, but patient safety requires provider notification first to manage potential adverse outcomes.