A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?
Report the concern to the charge nurse.
Question the nurse who worked the shifts in question.
Notify the pharmacy that the medication was not given.
Document the client's claim in the nurses' notes.
The Correct Answer is A
A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.
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Correct Answer is B
Explanation
A. Offering suggestions demonstrates a directive approach rather than a laissez-faire style, which typically involves minimal guidance.
B. Encouraging the AP to decide how they would like to divide client care tasks exemplifies laissez-faire leadership, as it empowers team members to make decisions independently.
C. Instructing the AP to report hourly indicates a more authoritarian leadership style, as it sets specific expectations for accountability.
D. Providing constructive criticism suggests active involvement in guiding the AP’s performance, contrasting with the hands-off approach of laissez-faire leadership.
Correct Answer is B
Explanation
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B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).
C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.