A nurse in a community clinic is caring for a client who has erythema migrans. The nurse should implement which of the following precautions?

Rationale:

A. Compare the current infusion with the prescription in the client's medication record: The first action is to verify the actual prescription against the current IV infusion. This ensures that the client is receiving the correct medication, dose, and rate, and allows the nurse to identify any errors or discrepancies before taking further action.

B. Submit a written warning for the nurse involved in the incident: Disciplinary action is not appropriate as an initial step. The priority is client safety and verifying facts, not assigning blame. Investigations or corrective actions follow after assessment and verification.

C. Complete an incident report and place it in the client's medical record: Incident reports are used to document discrepancies or errors, but they should not be placed in the medical record. They are submitted to risk management or quality assurance separately. Filing in the medical record could create legal and confidentiality issues.

D. Contact the charge nurse to see if the prescription was changed: While notifying the charge nurse may be necessary, it should occur after verifying the prescription and confirming the discrepancy. Immediate assessment and comparison to the medication record take priority to ensure client safety.

Rationale:

A. Remove stopcocks from IV tubing: Removing stopcocks is not necessary and may compromise IV line function. The priority is to prevent contact with latex-containing components, not to eliminate all IV hardware, as many are latex-free.

B. Disinfect and powder any latex products before use: Powdered latex products increase the risk of airborne latex particles, which can trigger severe allergic reactions. Disinfecting or using powdered latex items is unsafe for clients with latex sensitivity and should be avoided entirely.

C. Tape stockinet over monitoring devices and cords: Covering monitoring devices, cords, and other equipment with a barrier such as stockinet prevents direct contact with latex-containing components. This reduces the risk of an allergic reaction during surgery while allowing the necessary monitoring and functionality to continue safely.

D. Schedule the client as the last surgery of the day: While scheduling considerations may be made to reduce exposure to residual latex or disinfectants, the timing of surgery is not the primary strategy for preventing a reaction. The focus should be on removing or isolating all latex-containing items from the environment.