A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?

A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.
While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.
Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.

Incident report

In the given scenario, where the nurse inadvertently administers 2 tablets of acetaminophen with codeine instead of the prescribed dose of 1 tablet, the nurse should document this client care incident in an incident report.

An incident report is a formal record that documents any unexpected or adverse events that occur during the provision of healthcare. It serves as a tool for identifying and addressing potential risks and improving patient safety. The incident report should include a detailed account of what happened, including the date, time, individuals involved, description of the incident, and any potential harm or actual harm caused to the client. It should be completed as soon as possible after the incident occurs.

Provider's progress notes in (option A) is incorrect: Provider's progress notes are used to document the healthcare provider's assessment, diagnosis, treatment plan, and progress of the client's condition. It is not the appropriate place to document a client care incident like an administration error.

Controlled substance inventory record in (option C) is incorrect: The controlled substance inventory record is used to track the use and documentation of controlled substances in a healthcare facility. While medication errors involving controlled substances should be reported and documented, the controlled substance inventory record is not the appropriate place for documenting a client care incident.

Nursing care plan in (option D) is incorrect: The nursing care plan outlines the client's nursing diagnoses, goals, and nursing interventions. It is not the appropriate place to document a client care incident like a medication administration error.