A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan care?

Rationale:
A. Ensure the medication is administered within 3 hr of the scheduled time: Medications should typically be administered within 30 minutes before or after the scheduled time, not within 3 hours. Administering too early or too late can reduce therapeutic effectiveness or cause harm, depending on the medication type.

B. Use two identifiers to verify the client’s identity: Verifying identity with two identifiers—such as name and date of birth—ensures the right client receives the right medication. This practice aligns with the “five rights” of medication administration and is a critical step in preventing medication errors.

C. Document administration of the client’s routine medications at the beginning of the shift: Documentation should occur immediately after medication administration, not beforehand. Charting in advance increases the risk of errors and creates false records if the medication is delayed or omitted.

D. Check the label of the medication twice prior to administration: The nurse must check the medication label three times—when removing it from storage, before preparing it, and immediately before administration. Checking only twice does not meet safety standards.

Rationale:

• "We should notify the provider if the cast becomes loose over time.": A loose cast can fail to immobilize the fracture properly, risking displacement or delayed healing. Recognizing this and contacting the provider demonstrates proper understanding of cast care.

• "We should expect the swelling and tingling to worsen before it gets better.": While mild swelling and tingling may occur, increasing or worsening neurovascular symptoms can indicate complications such as compartment syndrome. The parent needs reinforcement that any worsening sensation or cold fingers should prompt immediate provider notification rather than being expected.

• "We need to be very careful about how we handle the cast for the first 2 days while it dries.": Handling a wet cast improperly can deform it and compromise fracture stabilization. Awareness of this indicates correct knowledge of initial cast care.

• "It is important that our child avoids placing anything inside the cast.": Inserting objects into the cast can cause skin irritation, pressure ulcers, or infection. Avoiding this demonstrates understanding of safe cast management.

• "We should prop the casted arm on pillows for the next 24 hours.": Elevation of the casted limb reduces swelling and promotes comfort. This reflects correct knowledge of post-cast care.