A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document as decreasing the risk for skin breakdown?

A. Report the occurrence to the nursing supervisor:

While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.

B. Complete an incident report stating the facts of the situation:

Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.

C. Verify the DNR prescription is current in the medical record.

Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.

D. Request a meeting with the ethics committee:

Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.

A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.

B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.

C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.

D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.