A nurse is discussing issues regarding controlled substances and reporting with a newly licensed nurse in an inpatient facility. Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching?

Rationale:

A. A nurse finds medication on the client’s bedside table upon entering the room: While this is a safety concern, it may not necessarily require an incident report unless it resulted in harm or was due to a medication error. It should be documented and investigated, but may not meet the threshold for a formal report depending on facility policy.

B. A client's MAR indicates the 0800 dose of furosemide 20 mg was administered at 0500: This represents a medication administration error—giving the drug significantly earlier than prescribed. Administering time-sensitive medications outside the scheduled time can affect patient safety and should be reported using an incident report for evaluation and prevention.

C. A client's MAR indicates the 0800 dose of morphine was withheld because the client refused to take the medication: Client refusal of medication is not an error and does not require an incident report. It should be documented in the medical record along with any related assessments or follow-up, but it is not a reportable incident.

D. A nurse finds a secondary infusion bag of an antibiotic that finished infusing 1 hr ago hanging at the client’s bedside: This situation suggests a delay in removing the IV bag, which is a minor deviation from ideal practice but typically does not require an incident report unless there was harm, contamination, or risk of adverse outcome.

Rationale:

A. Urinary frequency: As death approaches, urinary output typically decreases due to reduced kidney perfusion. Urinary frequency is not a common sign of impending death and may suggest other unrelated conditions.

B. Difficulty swallowing: Difficulty swallowing is a common manifestation of impending death. As muscle tone declines, the child may struggle to manage secretions or food, increasing the risk of aspiration and signaling the body is shutting down.

C. Decreased sleep: Clients nearing death often exhibit increased sleep or lethargy, not decreased sleep. Diminished responsiveness and longer periods of unresponsiveness are expected in the final stages of life.

D. Increased senses: Sensory function generally declines as death nears. Vision, hearing, taste, and touch may all diminish, and the child may become less responsive to external stimuli. Increased senses are not expected at this stage