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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.
B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.
C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."
D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.
Correct Answer is D
Explanation
Rationale:
A. Providing a back rub can be done by an AP, as it does not require specialized nursing skills.
B. Transporting a client is an appropriate task for an AP if the client is stable.
C. Performing oral hygiene for a postoperative client can be managed by an AP with supervision.
D. Removing and cleaning the cannula of a new tracheostomy requires specific skills and knowledge that only a licensed nurse should perform to avoid complications.
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