A nurse is reviewing a client's medical record and discovers that the client received a double dose of a prescribed medication. Which of the following actions should the nurse take?
Contact the nurse from the previous shift to report the doubled dose.
Document the doubled dose in the client's medical record.
Place a copy of the incident report in the client's record.
Report the incident to the manager of the pharmacy.
The Correct Answer is B
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Delegate low-skilled tasks to assistive personnel.
Delegating low-skilled tasks to assistive personnel is not consistent with the total patient care delivery method. In this model, the nurse assumes responsibility for providing comprehensive care to a smaller number of patients rather than delegating tasks to others. The nurse remains directly involved in all aspects of patient care, including assessment, planning, implementation, and evaluation.
B. Receive cross-training in multiple departments
Receiving cross-training in multiple departments may be beneficial in some healthcare settings but is not a characteristic of the total patient care delivery method. This model focuses on nurses providing individualized care to a specific group of patients within their assigned unit. Cross-training in multiple departments would not align with this model, as it could lead to divided attention and potentially compromise the quality of care provided.
C. Perform a specific nursing task for a group of clients.
Performing a specific nursing task for a group of clients is not consistent with the total patient care delivery method. In this model, the nurse is responsible for providing comprehensive care to a smaller number of patients, rather than focusing on specific tasks for multiple patients. Each patient's care is individualized and encompasses all aspects of nursing care, not just specific tasks.
D. Provide complete care for a caseload of clients.
Providing complete care for a caseload of clients is characteristic of the total patient care delivery method. In this model, the nurse assumes responsibility for the holistic care of a smaller number of patients during each shift. This approach allows for continuity of care, fosters therapeutic nurse-patient relationships, and promotes better patient outcomes.
Correct Answer is A
Explanation
A) Initiate oxygen therapy via nasal cannula for a client who has COPD:
Clients with chronic obstructive pulmonary disease (COPD) often have impaired gas exchange and may experience acute exacerbations requiring oxygen therapy to improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical intervention to address hypoxemia and prevent complications such as respiratory failure. Therefore, initiating oxygen therapy for a client with COPD is the highest priority among the options provided.
B) Initiate a 24-hr urine collection for a client who has end-stage kidney disease:
Initiating a 24-hour urine collection is an important nursing task for clients with end-stage kidney disease to monitor renal function and assess urine output. However, compared to the immediate need for oxygen therapy in a client with COPD, starting a urine collection is a lower priority and can be scheduled once the client's respiratory needs are addressed.
C) Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:
Administering antibiotics for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection is important to control the spread of infection and prevent complications. However, unless the client's condition is critically unstable or the antibiotic administration is time-sensitive, addressing oxygenation needs for a client with COPD takes precedence due to the potential for respiratory compromise and hypoxemia.
D) Change the dressing for a client who has a decubitus ulcer:
Changing dressings for clients with decubitus ulcers is essential for wound care management and prevention of infection. While maintaining skin integrity is important, addressing respiratory distress in a client with COPD is a higher priority to ensure adequate oxygenation and prevent respiratory compromise.
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