A nurse is reviewing the medication administration record (MAR) of a client who requires fluticasone MDI one puff and albuterol MDI two puffs. Which of the following actions should the nurse plan to take? Place the following steps in the correct order. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)
Have the client take one puff of albuterol
Have the client rest for 1 min
Have the client take the second puff of albuterol
Have the client rest for 5 min
Have the client take one puff of fluticasone
The Correct Answer is A, B, C, D, E
Rationale:
- Administering albuterol first is crucial because it is a bronchodilator that will help open the airways before administering the anti-inflammatory fluticasone.
- The client should rest for 1 minute between puffs of albuterol to allow for the medication to take effect.
- After taking the second puff of albuterol, a longer rest of 5 minutes allows the client to experience the full effects of the bronchodilator.
- Finally, administering fluticasone afterward will help reduce inflammation in the airways, maximizing the benefit of both medications.
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Correct Answer is A
Explanation
Rationale:
A. Albuterol: This is a bronchodilator that can cause side effects such as increased heart rate and chest pain due to its stimulant effect on the cardiovascular system.
B. Furosemide: This diuretic is unlikely to cause chest pain directly; however, it may lead to electrolyte imbalances that can indirectly affect cardiac function.
C. Digoxin: While digoxin has several potential side effects, chest pain is not commonly recognized as a direct adverse effect of this medication.
D. Atenolol: This medication is a beta-blocker used to manage hypertension and is unlikely to cause chest pain; rather, it may help alleviate angina symptoms.
Correct Answer is C
Explanation
Rationale:
A. Delaying the incident report until the end of the current shift can compromise the timely documentation of the error and any necessary interventions that may arise.
B. While it's important to notify risk management, the priority should be to document the incident immediately after assessing the client to ensure a complete record of the error.
C. Completing the incident report as soon as the assessment is complete is the most appropriate action, allowing for prompt documentation of the error and any potential effects on patient care.
D. Informing the previous nurse is necessary for communication, but it should not delay the completion of the incident report, which is crucial for tracking errors and improving safety protocols.