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What times should the nurse measure vital signs? Select all that apply

 

Choice A rationale

Beginning cardiopulmonary resuscitation (CPR) and calling a code would be inappropriate in this situation because the client has a signed do not resuscitate (DNR) form. A DNR order is a legal document that instructs healthcare providers not to perform CPR if the client’s heart stops or if they stop breathing. Performing CPR would go against the client’s wishes and legal rights.

Choice B rationale

Asking the unlicensed assistive personnel (UAP) to complete postmortem care is not the immediate next step. While postmortem care is necessary, the nurse must first report the client’s status to the healthcare provider to ensure proper documentation and follow-up actions.

Choice C rationale

Reporting the client’s status to the healthcare provider is the correct action. This ensures that the healthcare provider is aware of the client’s condition and can provide further instructions or documentation as needed. It is essential to follow the proper chain of command and legal protocols in such situations.

Choice D rationale

Notifying the family of the client’s death is important, but it is not the immediate next step. The nurse should first report the client’s status to the healthcare provider to ensure that all necessary medical and legal documentation is completed before contacting the family.

Choice A rationale

Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.

Choice B rationale

This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.

Choice C rationale

Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.

Choice D rationale

Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.

Choice E rationale

Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.

Choice F rationale

Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.