A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Completion of the incident report
Time the medication was given
Reason for the medication error
Notification of the pharmacist
The Correct Answer is B
A is incorrect because the completion of the incident report should not be documented in the client's medical record, but in a separate file for quality improvement purposes.
B is correct because the time the medication was given is an essential fact related to the incident that should be documented in the client's medical record.
C is incorrect because the reason for the medication error should not be documented in the client's medical record, but in the incident report for analysis and prevention of future errors.
D is incorrect because the notification of the pharmacist should not be documented in the client's medical record, but in the incident report for follow-up and corrective actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Request a PRN restraint prescription for clients who are aggressive. Using restraints as a PRN (as-needed) intervention for clients who are aggressive is not appropriate. Restraints should only be used as a last resort when all other non-restraint interventions have been unsuccessful in managing the client's behaviour. Restraints should never be used as a means of punishment or control.
Choice B reason:
It is essential to release the restraints periodically to assess the client's condition, skin integrity, and circulation. Restraints should never be left on continuously without regular checks and re-evaluation of the client's need for restraint use.
Choice C reason:
Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.
Choice D reason
Document the client's condition every 15 minutes. While it is essential to document the client's condition regularly when restraints are in use, documenting every 15 minutes might not be sufficient for thorough assessment and monitoring. The frequency of documentation should be more frequent, ideally every 2 hours or according to facility policy, and should include the client's physical and mental status, behaviour, skin integrity, and any signs of distress or complications related to the use of restraints.
Correct Answer is B
Explanation
A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities.
When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
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