Which nursing diagnosis is most appropriate for a patient with xerostomia?

Choice A reason: This is an incorrect choice because exposure-related accident is not the type of error when the wrong type of medication is administered to the patient. Exposure-related accident is an incident that occurs when a person is exposed to a harmful substance or environment, such as radiation, chemicals, or extreme temperatures.

Choice B reason: This is the correct choice because procedure-related accident is the type of error when the wrong type of medication is administered to the patient. Procedure-related accident is an incident that occurs when a person is harmed by a medical or surgical procedure, such as a wrong-site surgery, a medication error, or a catheter infection.

Choice C reason: This is an incorrect choice because organization-related accident is not the type of error when the wrong type of medication is administered to the patient. Organization-related accident is an incident that occurs due to a failure of the system or the management of an organization, such as a lack of communication, a poor policy, or a staffing shortage.

Choice D reason: This is an incorrect choice because equipment-related accident is not the type of error when the wrong type of medication is administered to the patient. Equipment-related accident is an incident that occurs due to a malfunction or misuse of a device or a machine, such as a ventilator, a defibrillator, or a syringe.

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats.