A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)
The name of the provider who prescribed the medication
The time the client was to receive the medication
The date of the Incident
The client's vital signs
The potential adverse effects of the medication
Correct Answer : B,C
Rationale:
A. The name of the provider who prescribed the medication is not necessary for the variance report; focus should be on the incident itself.
B. The time the client was to receive the medication should be included to document the discrepancy accurately.
C. The date of the incident is essential for accurate record-keeping and follow-up.
D. The client's vital signs are not relevant to the variance report about the missed medication unless directly related to the incident.
E. The potential adverse effects of the medication are not typically included in the incident report but might be noted in the client's ongoing care plan.
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Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.
B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.
C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.
E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.
Correct Answer is D
Explanation
Rationale:
A. Insisting the client take medications does not respect the client’s autonomy and is not an advocacy action.
B. Informing the client that the medication is the same as taken at home does not necessarily address the client’s concerns or questions.
C. Telling the client that refusal is noncompliance does not support client autonomy and does not address their concerns.
D. Encouraging the client to verbalize questions supports their right to be informed and make decisions about their care, demonstrating advocacy.