A nurse is planning care for a client who is 6 hr. postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's plan of care?

Choice A Reason:

A nurse discovers that a client's family member has administered a PCA dose: While this is a medication administration concern, it might not always require an incident report, but it should be addressed by the healthcare team to prevent future occurrences.

Choice B Reason:

A nurse observes a client vomiting after receiving an oral pain medication: This could be a medication reaction or a side effect, and it should be documented in the client's medical record, but it may not necessarily require a separate incident report.

Choice C Reason:

A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. Incident reports are typically used to document unexpected events or situations that deviate from the standard of care, and this includes situations where errors occur that could potentially harm the patient. In this case, the IV pump delivering twice the prescribed amount of fluid is a medication error that should be reported to document the occurrence and to ensure that corrective actions are taken to prevent similar incidents in the future.

Choice D Reason:

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: This might be a situation that requires clarification and discussion among the healthcare team, but it may not necessarily require an incident report unless there is concern about patient safety.

Choice A Reason:

Yellow patches in the mouth. Yellow patches in the mouth are indicative of a candida infection, specifically oral candidiasis, which is commonly known as thrush. Candida is a type of yeast that can overgrow in the mouth, leading to the development of creamy or yellowish-white patches on the tongue, inner cheeks, and other oral mucosal surfaces. These patches are often described as "cottage cheese-like" in appearance.

Choice B Reason:

Brittle nails are more commonly associated with conditions like fungal nail infections or nail trauma.

Choice C Reason:

Night sweats can occur for various reasons, including hormonal changes, infections, or underlying medical conditions, but they are not specific to candida infections.

Choice D Reason:

Hearing loss is not a typical symptom of candida infections but may be associated with ear infections or other ear-related conditions.