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

Answer and Explanation

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.
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Correct Answer is D

Explanation

The nurse should not include the client's frequency of call button use in the change-of-shift report. While this information might seem relevant, it can be misinterpreted and stigmatize the client. Sharing call button frequency without context could lead assumptions about the client being overly demanding or attention-seeking, instead of focusing on their potential needs and anxieties post-surgery.

Here's why the other options are acceptable to include:

a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
b. The client's most recent ventilator settings:Although the client is weaned, knowing their past ventilator settings provides valuable insight into their respiratory function and potential risks for decompensation.
c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.

Therefore, the best answer is d. The frequency in which the client presses the call button.

Remember, a good change-of-shift report focuses on crucial clinical information relevant to the client's current condition and care plan, avoiding subjective observations that could lead to bias or misjudgment.

A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A middle adult client who has unstable vital signs

Correct Answer is D

Explanation

- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.

- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.

- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.

- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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