A nurse is measuring a client’s oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

A: Verifying the medication against the prescription and medication label is a correct and essential step in ensuring the right medication is given to the right patient.

B: Documenting medication administration prior to administering is incorrect and can lead to errors. Documentation should occur immediately after the medication is given to ensure accuracy and prevent discrepancies.

C: Scanning the bar code on the medication administration record and the client’s arm band is a correct practice that helps verify the patient’s identity and the medication being administered.

D: Checking the provider’s orders and confirming the dosage is a necessary step to ensure the correct medication and dose are given. This action is part of safe medication administration practices.

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.