A home health nurse is reinforcing teaching with a client who has diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's use of a glucometer?

A.While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.

B.An error in fluid administration by an IV pump, especially when it involves delivering twice the prescribed amount, is a medication error that could have serious consequences, such as fluid overload or electrolyte imbalances. An incident report must be filed to document the event and investigate what went wrong with the equipment.

C.Removing wrist restraints one at a time, particularly when the client is calm, follows safe practice to prevent injury. This situation does not represent an error, violation, or adverse event, and does not require an incident report. Restraints should always be removed cautiously and gradually to ensure client safety.

D.A client vomiting after receiving an oral pain medication could be an adverse drug reaction. While this is important to document in the patient’s medical record, it may not always require an incident report unless it leads to further complications or indicates a medication error.

The correct answer is A. Clean the wound from the center to the outer edges.

Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.

The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.