A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Request a medication reconciliation form from the pharmacy.

Ask the client if she received the 1700 medication.

Contact the previous nurse to determine if the client received the medication.

Administer the medication and document the current time.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.

Choice B Reason:

Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.

Choice C Reason:

Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.

It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.

Choice D Reason:

Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.

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Correct Answer is C

Explanation

A. A family member is napping in the client's room.

This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.

B. A client refuses to eat at mealtime.

Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.

C. A client's bed alarm is malfunctioning.

This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.

D. An assistive personnel is late for the upcoming shift.

Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.

A. Increase in fluid requirements B. Decrease in vitamin intake C. Increase in protein requirements D. Decrease in muscle mass

Correct Answer is D

Explanation

Choice A Reason:

Increase in fluid requirements is incorrect. An increase in fluid requirements is more likely to contribute to changes in fluid balance and not necessarily to long-term weight gain. While short-term fluctuations in fluid retention can affect weight, sustained weight gain is not typically attributed to increased fluid intake.

Choice B Reason:

Decrease in vitamin intake is incorrect. While inadequate vitamin intake can have various health implications, direct weight gain is not a typical outcome. However, a poor diet that lacks essential nutrients, including vitamins, can lead to overall health issues, potentially influencing weight management indirectly.

Choice C Reason:

Increase in protein requirements is incorrect. An increase in protein requirements, in itself, is not likely to result in weight gain. However, a diet with an excess of calories, including proteins, can contribute to weight gain. It's essential to consider the overall dietary balance and caloric intake.

Choice D Reason:

Decrease in muscle mass is correct. Decrease in muscle mass, known as sarcopenia, is a common age-related change. As muscle mass decreases, there can be a reduction in metabolic rate, potentially leading to weight gain. Additionally, the loss of muscle may be accompanied by an increase in fat mass, contributing to changes in overall body composition.

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A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

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