31 a nurse is performing morning rounds for a client

31.
A nurse is performing morning rounds for a client and finds the client's bedtime
medications sitting at the bedside in a medication cup. Which of the following
actions should the nurse take?
Contact the charge nurse to complete an incident report.
The person who discovers the incident should complete the incident report as soon
as possible, even if it is not the same staff member who was involved in the
incident.
Document the missed medication administration in the client's medical record.
It is the responsibility of the nurse to record the facts of the missed medication
administration in the client's medical record. There should be enough information
about the event so that treatment can be provided if needed.
Request that the nurse who prepared the bedtime medications complete a report.
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MY ANSWER
It is the responsibility of the nurse who discovers an incident to report it and
complete the incident report. The facility will investigate the incident.
Place a copy of an incident report in the client's medical record.
The nurse should not place a copy of the incident report in the client's medical
record. This report is considered confidential communication and is used by the
facility to alert the risk manager of the event.
32.
A nurse is prioritizing care for four clients. Which of the following clients is the
nurse's priority?
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A client who is postoperative following a thyroidectomy and reports tingling
around their mouth.
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the client who is postoperative following a thyroidectomy and
reports tingling around their mouth is the priority. The client could be experiencing
hypocalcemia which can lead to tetany and respiratory distress. The nurse should
assess the client for muscle twitching and respiratory distress and be prepared to
administer IV calcium gluconate or calcium chloride.
A client who is postoperative following a total hip arthroplasty and reports a pain
level of 6 on a pain scale of 0 to 10.
The nurse should identify that pain level of 6 on a 0 to 10 numeric pain scale is
nonurgent because it is an expected finding for a client who is postoperative
following a total hip arthroplasty. Therefore, there is another client that is the
priority. The client might require repositioning, ice, or analgesics to promote
comfort and relieve pain.
A client who is postoperative following a stapedectomy and reports vertigo.
The nurse should identify that vertigo is nonurgent because it an expected finding
in a client following a stapedectomy due to irritation of the inner ear. Therefore,
there is another action that is the priority.