A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
How many popsicles are available.
The color and flavor of gelatin used.
If the popsicles are completely frozen.
Whether they contain pulp or fruit.
The Correct Answer is C
Choice A rationale
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.
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Correct Answer is D
Explanation
Choice A rationale
Double-checking all dosage calculations is a crucial step in preventing medication errors. This process involves verifying the calculations to ensure the correct dose is administered. However, while important, it is not the most effective technique on its own. It must be combined with other strategies to ensure comprehensive error prevention.
Choice B rationale
Identifying unusually large or small doses is essential in preventing medication errors. This involves recognizing doses that fall outside the typical range for a given medication and patient population. However, this technique alone does not address other potential errors, such as patient misidentification or incorrect medication administration.
Choice C rationale
Comparing the medication label to the order is a fundamental step in preventing medication errors. This process ensures that the correct medication is being administered as per the physician’s order. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.
Choice D rationale
Using at least two client identifiers before administering a dose is the most effective technique in preventing medication errors. This process ensures that the correct patient is receiving the correct medication. It addresses the critical issue of patient misidentification, which is a common cause of medication errors. By confirming the patient’s identity using two identifiers, such as name and date of birth, the risk of administering medication to the wrong patient is significantly reduced.
Choice E rationale
Involving and educating clients in medication administration is an important strategy in preventing medication errors. Educated clients are more likely to understand their medication regimen and recognize potential errors. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is a crucial step in preventing medication errors. This process ensures that there is an accurate and up-to-date record of all medications administered. However, this technique alone does not address other potential errors, such as incorrect dosage calculations or patient misidentification.
Correct Answer is D
Explanation
Choice A rationale
This outcome statement focuses on the client’s ability to perform a specific task related to ostomy care. While it’s important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.
Choice B rationale
This outcome statement indicates the client’s attempt to self-administer insulin but inability to perform the injection. While it’s important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.
Choice C rationale
This outcome statement focuses on monitoring the client’s respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client’s primary health concern in this scenario, which is managing hyperglycemia and insulin administration.
Choice D rationale
This outcome statement directly addresses the client’s need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client’s health needs and goals following the surgical procedure and the development of hyperglycemia.