A nurse is assisting with the care of a client in an outpatient clinic.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should prepare to administer naloxone and

The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.

A.While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.

B.An error in fluid administration by an IV pump, especially when it involves delivering twice the prescribed amount, is a medication error that could have serious consequences, such as fluid overload or electrolyte imbalances. An incident report must be filed to document the event and investigate what went wrong with the equipment.

C.Removing wrist restraints one at a time, particularly when the client is calm, follows safe practice to prevent injury. This situation does not represent an error, violation, or adverse event, and does not require an incident report. Restraints should always be removed cautiously and gradually to ensure client safety.

D.A client vomiting after receiving an oral pain medication could be an adverse drug reaction. While this is important to document in the patient’s medical record, it may not always require an incident report unless it leads to further complications or indicates a medication error.