Nokea
A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:
- A. The reason for administering the wrong dose
- B. The type of drug involved
- C. The amount of insulin that was given
- D. Any adverse effects on the client
Correct Answer: A
Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.
You may also like to solve these questions
While performing CPR, a healthcare provider encounters a client with a large amount of thick chest hair when preparing to use an automated external defibrillator (AED). What is the next appropriate action for the healthcare provider?
- A. Apply the pads to the chest and provide a shock
- B. Wipe the client's chest down with a towel before applying the pads
- C. Shave the client's chest to remove the hair
- D. Do not use the AED
Correct Answer: C
Rationale: When using an AED, it is crucial for the pads to have good contact with the skin to effectively deliver an electrical shock. While AED pads can adhere to a client's chest even with some hair, thick chest hair can hinder proper current conduction. In such cases, it is recommended to shave the area of the chest where the pads will be applied. Most AED kits include a razor for this purpose. The healthcare provider should act promptly to minimize delays in defibrillation. Option A is incorrect because it may lead to ineffective treatment due to poor pad adherence. Option B is not the best course of action as wiping the chest may not resolve the issue of poor pad contact. Option D is incorrect as not using the AED could jeopardize the client's chance of survival in a cardiac emergency.
What is the primary route of transmission of MRSA?
- A. Shared needles
- B. Hands of healthcare workers
- C. Items in the healthcare environment
- D. Blood transfusions
Correct Answer: B
Rationale: The correct answer is 'Hands of healthcare workers.' MRSA is primarily transmitted via the unwashed hands of healthcare workers who can carry the Staphylococcus aureus bacterium from one patient to another. Shared needles, items in the healthcare environment, and blood transfusions are not the main routes of transmission for MRSA. Shared needles can transmit bloodborne pathogens, items in the healthcare environment can harbor bacteria but are not the primary mode for MRSA, and blood transfusions are not a common route for MRSA transmission.
A client is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?
- A. Assist the client to shower as ordered and monitor the site for further changes
- B. Instruct the client to lie prone to allow the site to dry
- C. Place antibiotic ointment and a sterile dressing over the site
- D. Notify the physician for an antibiotic order
Correct Answer: A
Rationale: An incision that appears slightly red with a small amount of serous drainage on the first day following surgery is going through a normal healing process. It is important to keep the incision clean. In this case, the nurse should assist the client to shower as ordered to maintain hygiene and monitor for changes in the incision site. Instructing the client to lie prone may not be necessary and could cause discomfort. Applying antibiotic ointment without a specific order is not recommended as it can interfere with the healing process. Notifying the physician for an antibiotic order is premature at this stage since the incision is showing normal signs of healing.
A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct Answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
A physician has ordered that a client must be placed in a high Fowler's position. How does the nurse position this client?
- A. The client is placed face-down
- B. The client lies on his back with his head lower than his feet
- C. The client lies on his back with the knees drawn up toward the chest
- D. The client is sitting with the backrest at a 90-degree angle
Correct Answer: D
Rationale: A high Fowler's position is a modification of the semi-Fowler's position, in which the client is seated with arms resting at the sides or in the lap. The high Fowler's position requires that the client's head and upper chest are elevated, and the backrest is at a 90-degree angle. This position supports breathing and appropriate chest wall movement, making it easier for the client to breathe. Choices A, B, and C are incorrect because a high Fowler's position involves the client being in a sitting position with the backrest at a 90-degree angle, not being face-down, lying with the head lower than the feet, or lying on the back with knees drawn up towards the chest.