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 D
Explanation
A. Asking each nurse for information about the problem is essential, but it should occur after addressing the immediate need for privacy.
B. Listening to the concerns of each staff nurse is important, but doing so in a private area ensures confidentiality and reduces further escalation.
C. Discussing ways to resolve the conflict is necessary, but first creating a safe and private environment is vital for open communication.
D. Moving the staff nurses to a private area is the first step to ensure they can discuss their conflict without external pressures or interruptions, which facilitates a more constructive dialogue.
Correct Answer is A
Explanation
A. Reporting the incident to the manager of the pharmacy is the appropriate action to ensure that the medication error is addressed and investigated properly, as this can help prevent future occurrences.
B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.
C. Documenting the doubled dose in the client's medical record does not fulfill the legal requirements for reporting medication errors and could mislead future care providers about the medication administration history.
D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.