A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching?

A. A client received gentamicin intermittent IV bolus over 1 hr:

While gentamicin is typically administered as an intermittent IV bolus, the rate of administration over 1 hour is not necessarily inappropriate. However, the specific institutional protocol or medication administration guidelines should be followed. If the rate of administration deviates significantly from the standard protocol or manufacturer's recommendations, it may warrant further investigation but may not necessarily require an incident report.

B. A nurse used a 25-gauge 3-inch needle to administer a heparin injection:

Using a 25-gauge 3-inch needle for heparin injection is not standard practice and may not be the most appropriate needle size for subcutaneous administration. However, it does not necessarily indicate a need for an incident report unless it resulted in harm to the client. It may prompt further education or clarification regarding appropriate needle selection for subcutaneous injections.

C. A nurse injected Demerol IM into the vastus lateralis site of an adult:

While Demerol (meperidine) is typically administered intramuscularly, the choice of the vastus lateralis site for injection in an adult may not be the most common practice, but it is an acceptable site for IM injections. Unless there are specific contraindications or adverse outcomes related to the site selection, this finding may not require an incident report. However, it could prompt a review of injection site selection guidelines or further education.

D. A client received a crushed bupropion XL tablet mixed with applesauce:

This finding indicates a need for an incident report. Bupropion XL (extended-release) tablets should not be crushed or chewed, as this can lead to rapid release and absorption of the medication, potentially causing adverse effects or toxicity. Administering crushed extended-release tablets is a medication error that warrants an incident report to document the event, assess potential harm to the client, and implement corrective actions to prevent recurrence.

A. Clamping the catheter: Clamping the catheter may interrupt the flow of fluids or medications, which could worsen the client's condition. This action is not appropriate as the first intervention.

B. Initiate oxygen therapy: Acute shortness of breath is a critical symptom that requires immediate intervention to ensure adequate oxygenation. Initiating oxygen therapy is the priority action to improve the client's oxygenation status while further assessment and interventions are conducted.

C. Auscultate breath sounds: Assessing breath sounds is an essential component of the assessment for a client experiencing shortness of breath. However, in this scenario, the priority is to ensure the client's oxygenation needs are met by initiating oxygen therapy first.

D. Position the client in left lateral Trendelenburg: Positioning the client in left lateral Trendelenburg may help optimize oxygenation by improving blood flow and ventilation-perfusion matching. However, this action is not the priority compared to initiating oxygen therapy, which directly addresses the client's respiratory distress.