A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)
The name of the provider who prescribed the medication
The time the client was to receive the medication
The date of the Incident
The client's vital signs
The potential adverse effects of the medication
Correct Answer : B,C,D
Rationale:
A. The name of the provider who prescribed the medication is not necessary for the variance report; focus should be on the incident itself.
B. The time the client was to receive the medication should be included to document the discrepancy accurately.
C. The date of the incident is essential for accurate record-keeping and follow-up.
D. The client's vital signs such as blood pressure are especially relevant for medications like furosemide, which affects fluid balance and blood pressure. These values help assess for harm or trends following the missed dose.
E. The potential adverse effects of the medication are not typically included in the incident report but might be noted in the client's ongoing care plan.
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Related Questions
Correct Answer is B
Explanation
Rationale:
A. Applying restraints to prevent an alert, oriented client from leaving AMA: This is an example of false imprisonment, not negligence.
B. Negligence is the failure to act as a reasonably prudent nurse would under similar circumstances. Notifying the provider hours after discovering absent peripheral pulses shows a delay in appropriate action, which can lead to serious complications (e.g., compartment syndrome, tissue ischemia). This failure to act promptly meets the definition of negligence.
C. Administering medication without the client’s knowledge after refusal: This constitutes battery, as it involves intentional, unauthorized physical contact.
D. Threatening to apply restraints if the client continues eating chips: This is assault, since it is a threat of harm without physical contact.
Correct Answer is A
Explanation
Rationale:
A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
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