A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Choice A Reason:
Checking the reading after the other nurse leaves the room is incorrect because it does not address the immediate need for accurate data and doesn't ensure that the initial readings were correct. It's important to act promptly to verify the accuracy of the readings to ensure patient safety.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is incorrect. While there seems to be a difference of 16 beats per minute between the apical and radial pulses, it's essential to confirm this discrepancy with further assessment rather than immediately documenting it. Documentation should be based on accurate and verified data.
Choice C Reason:
Report the results of the deficit to the healthcare provider is incorrect. Reporting the results to the healthcare provider without confirming the accuracy of the initial readings may lead to unnecessary alarm or inappropriate interventions. It's important to ensure the data is reliable before escalating to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is correct because it allows the nurses to confirm the accuracy of the initial readings and ensure that there is indeed a pulse deficit. This action promotes patient safety by obtaining reliable data for appropriate intervention if needed. It's crucial to rule out any errors or discrepancies in the initial readings before taking further action or reporting to the healthcare provider.

Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.