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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Place the client in a supine position:

Placing a client with pulmonary edema in a supine position can exacerbate symptoms by increasing venous return and worsening fluid accumulation in the lungs. Instead, positioning the client upright or in a semi-Fowler's position is more appropriate to facilitate respiratory mechanics and decrease venous return.

B) Weigh the client every other day:

Daily weight monitoring is crucial for clients with pulmonary edema to assess fluid balance accurately. Weighing the client every other day may not provide timely information on fluid retention and response to treatment. Therefore, daily weight measurement is typically recommended.

C) Encourage the client to ambulate three times per day:

While mobility is essential for overall health, clients with pulmonary edema may experience dyspnea and fatigue, limiting their ability to ambulate. Ambulation should be encouraged but should be tailored to the client's tolerance level and may need to be adjusted based on their respiratory status.

D) Report urine output less than 30 mL/hr:

Monitoring urine output is vital in clients with pulmonary edema to assess kidney perfusion and fluid balance. A urine output of less than 30 mL/hr may indicate decreased renal perfusion and impaired fluid clearance, which can exacerbate pulmonary congestion. Therefore, it is crucial to report such findings promptly for further evaluation and intervention.

A. Ask ambulatory clients to help to move clients in wheelchairs. B. Place dry towels around the bases of doors. C. Carry bedridden clients to safety by lifting them onto your back. D. Aim the extinguisher at the top of the fire.

Correct Answer is B

Explanation

A) Ask ambulatory clients to help to move clients in wheelchairs:

While enlisting the help of ambulatory clients to assist those in wheelchairs may seem logical, it is not typically recommended as it could pose safety risks to both parties during an evacuation. Assistive personnel should be trained to prioritize their own safety and the safety of others during evacuation procedures, following established protocols for assisting clients with mobility impairments.

B) Place dry towels around the bases of doors:

Placing dry towels around the bases of doors is a recommended fire evacuation procedure to prevent smoke from entering the room. This action helps create a barrier to smoke inhalation and can buy time for evacuation or rescue efforts. It is important to use dry towels or clothing to avoid fueling the fire and to minimize the passage of smoke.

C) Carry bedridden clients to safety by lifting them onto your back:

Carrying bedridden clients on one's back during a fire evacuation is not a safe or feasible method, especially for assistive personnel who may not have the physical strength or training to perform such tasks. Evacuating bedridden clients should be done using appropriate evacuation equipment such as evacuation sleds or sheets, following facility protocols and guidelines.

D) Aim the extinguisher at the top of the fire:

While using a fire extinguisher is an important aspect of fire safety training, aiming the extinguisher at the top of the fire is not always the correct approach. The appropriate technique for using a fire extinguisher depends on the type of fire and the specific instructions provided with the extinguisher. It is essential for assistive personnel to receive proper training on fire extinguisher use and to follow established procedures during emergencies.

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