Thirty minutes after receiving meperidine, the client develops a temperature of 101°F and the skin is warm and flushed with a notable rash on the chest and back. The nurse contacts the primary health care provider and begins to document on an incident report. Which information should be included?
The client had an allergic reaction to the ordered meperidine.
The primary health care provider was notified because the client developed a rash after receiving an opioid analgesic.
The client’s skin was warm and flushed, and a rash was noted on the chest and back.
Thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C).
The Correct Answer is D
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
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Correct Answer is D
Explanation
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.
Correct Answer is B
Explanation
Choice A rationale
Electrical cords placed along the walls are generally not a safety risk as long as they are secured and not in the walking path. This placement can actually reduce tripping hazards.
Choice B rationale
Scatter rugs are a significant safety risk for older adults with decreased vision. They can easily cause tripping and falls, which can lead to serious injuries.
Choice C rationale
Handrails in the bathroom are a safety feature that helps prevent falls and provides support for individuals with decreased vision or mobility issues.
Choice D rationale
Using a microwave for cooking is generally safe for older adults with decreased vision as it reduces the risk of burns and accidents associated with stovetop cooking.