While assessing a client at the beginning of the shift, a nurse notes that the client received a medication in error from the nurse on the previous shift. At which of the following times should the nurse plan to complete an incident report about the error?
After the end of the current shift
After contacting risk management
As soon as the assessment is complete
As soon as the nurse from the previous shift has been informed
The Correct Answer is C
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.
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Correct Answer is B
Explanation
Rationale:
A. Dyspepsia: While dyspepsia can be uncomfortable, it is not a critical finding that requires immediate reporting to the provider. It may be a common side effect of statins but typically does not warrant urgent intervention.
B. Elevated creatine kinase: An elevated creatine kinase level can indicate muscle damage, which is a serious side effect associated with rosuvastatin and other statins. This finding requires immediate reporting to prevent complications such as rhabdomyolysis.
C. Headache: A headache may occur with many medications and does not usually require immediate reporting unless it is severe or persistent.
D. Mostly cloudy: This option does not pertain to any specific clinical finding or symptom and is therefore not relevant to the question.
E. Decreased HDL cholesterol: While low HDL cholesterol can be a concern, it is not as urgent as elevated creatine kinase levels and typically does not require immediate action.
Correct Answer is D
Explanation
Rationale:
A. Mostly cloudy: This option appears to be incorrectly stated. It does not pertain to a critical client assessment related to morphine administration.
B. Apical heart rate: Monitoring the heart rate is important, but respiratory depression is a more immediate and life-threatening concern with morphine administration, so it is not the first priority.
C. Blood pressure: Morphine can cause hypotension, but this is not as critical as respiratory depression, which must be assessed first in opioid administration.
D. Respiratory rate: The most critical assessment when administering morphine is the respiratory rate, as opioid medications like morphine can cause respiratory depression, which can be life-threatening if not addressed.
E. Level of consciousness: While important, changes in consciousness typically follow respiratory depression, so assessing the respiratory rate takes priority.