A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

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.

The correct answer is choice C. The AP pulls the pinna up and back.

Choice A rationale:

Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.

Choice B rationale:

Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.

Choice C rationale:

Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.

Choice D rationale:

Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.