When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.

When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.

The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is the valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.

Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.

Option A is incorrect because explaining that the healthcare provider probably prescribed a different medication while he is hospitalized is not true or helpful, as it does not verify or resolve the issue.

Option B is incorrect because telling the client that he is probably confused since being hospitalized tends to disorient clients is rude and dismissive, as it does not acknowledge or address the client's concern.

Option D is incorrect because explaining that the pharmacy often substitutes generic equivalents for more expensive brands is not accurate or relevant, as it does not verify or resolve the issue.

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.