The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
Inform the pharmacist who dispensed the medication.
Evaluate the client for symptoms of a drug overdose.
Report the medication error to the nursing supervisor.
Review the medication transcription with the nurse.
The Correct Answer is B
Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.
Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.
Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.
Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.
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Correct Answer is D
Explanation
Choice A Reason: Managed healthcare plans do not pay for any in-hospital medical evaluations is not the best information for the nurse to provide this family. This statement is false and misleading. Managed healthcare plans may cover in-hospital medical evaluations if they are deemed medically necessary and authorized by the plan. The nurse should not discourage the family from seeking appropriate care for their mother based on inaccurate information.
Choice B Reason: Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital is not the best information for the nurse to provide this family. This statement is irrelevant and insensitive. Healthcare costs are influenced by many factors, such as technology, inflation, regulation, and demand. The nurse should not blame the clients for wanting to have diagnostic testing done in the hospital, which may be essential for their health and well-being.
Choice C Reason: The client is grieving normally in response to her husband's death and hospitalization is not necessary is not the best information for the nurse to provide this family. This statement is presumptuous and dismissive. Grief is a complex and individual process that may affect people differently. The nurse should not assume that the client's confusion and disorientation are normal signs of grief, which may mask underlying medical conditions that require evaluation and treatment.
Choice D Reason: Managed care providers have mandatory pre-certification requirements for hospitalization is the best information for the nurse to provide this family. This statement is factual and helpful. Pre-certification is a process by which managed care providers review and approve proposed hospital admissions, procedures, or services before they are performed. The nurse should inform the family that they need to obtain pre-certification from their mother's plan before admitting her to the hospital, or they may face denial of coverage or higher out-of-pocket costs.
Correct Answer is B
Explanation
A) This intervention is not appropriate because it violates the client's privacy and confidentiality. The health department does not need to be notified of the client's condition, as breast cancer is not a communicable disease or a public health threat. The nurse should respect the client's wishes and only share information with authorized persons or agencies.
B) This intervention is appropriate because it respects the client's autonomy and encourages informed decision-making. The nurse should advise the client to consider the benefits and risks of disclosing or withholding the diagnosis from the family, and how it may affect their relationships and support systems. The nurse should also provide relevant information and resources to help the client make an informed choice.
C) This intervention is not appropriate because it contradicts the client's decision and may cause confusion or distress for the family. The nurse should not suggest genetic screening to the family without the client's consent, as this may imply that they are at risk of developing breast cancer or other genetic disorders. The nurse should also avoid giving unsolicited advice or opinions that may interfere with the client's autonomy.
D) This intervention is not appropriate because it imposes the nurse's values and beliefs on the client. The nurse should not explain that the family has a right to know of potential health problems, as this may imply that the client is wrong or selfish for withholding the diagnosis. The nurse should acknowledge and respect the client's perspective and preferences, and support them in coping with their condition.
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