The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

A: The nurse is ultimately responsible for the error. Nurses are responsible for ensuring the correct administration of medications, which includes verifying the correct dosage. When a nurse administers medication, they must double-check the order, especially if it is unclear or illegible. In this case, the nurse misinterpreted the scribbled order and administered an incorrect dose, making them accountable for the error. Nurses are trained to seek clarification if there is any doubt about a medication order to prevent such mistakes.

B: The health care provider, while responsible for prescribing the medication, is not ultimately responsible for the administration error in this scenario. The provider’s role is to ensure that the prescription is clear and accurate. However, if the order is unclear, it is the nurse’s responsibility to seek clarification before administering the medication. The health care provider would be responsible if the error was due to a prescribing mistake, but in this case, the error occurred during the administration phase.

C: The hospital, as an institution, provides the environment and resources for patient care but is not directly responsible for individual medication administration errors. The hospital’s role includes ensuring that systems are in place for safe medication practices, such as proper training and protocols. However, the responsibility for the error lies with the individual who administered the medication incorrectly.

D: The pharmacist’s role is to dispense medications accurately and provide information about the medication. While pharmacists can catch potential errors in prescriptions, they are not responsible for the administration of the medication. In this case, the pharmacist would not be held accountable for the nurse’s misinterpretation and incorrect administration of the medication.

A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.

B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.

C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.

D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.