A. Reporting the incident to the manager of the pharmacy is the appropriate action to ensure that the medication error is addressed and investigated properly, as this can help prevent future occurrences.

B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.

C. Documenting the doubled dose in the client's medical record does not fulfill the legal requirements for reporting medication errors and could mislead future care providers about the medication administration history.

D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.

A. Setting specific times for low-priority tasks may not be the most efficient use of time, as client needs can change throughout the shift.

B. Performing complicated tasks independently may not be safe, as it is essential to collaborate with other healthcare team members when necessary for patient safety.

C. Postponing checking for new prescriptions until medications are due could lead to delays in care and negatively impact client outcomes; it's important to check for updates promptly.

D. Clustering care activities for each client promotes efficiency, minimizes interruptions, and helps ensure that all care needs are met in a timely manner.

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.

B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.

C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.

D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

A. Removing gloves before leaving an isolation room is appropriate practice and helps prevent the spread of infection.

B. Filling a basin with water at 40° C (104° F) is too hot for foot care and could lead to burns or injury; water temperature for foot care should be comfortably warm, typically around 37°C (98.6°F).

C. Instructing a client to look down at their feet when being assisted to ambulate is a safety measure that can help the client maintain balance and avoid tripping.

D. Applying water-soluble lubricant to the nares of a client receiving oxygen is a standard practice to prevent dryness and does not require intervention.

A. Encouraging the expression of feelings about illness can be a part of patient-centered care, but it does not fully encompass the role of advocacy, which involves more comprehensive support for the client's needs.

B. Reinforcing teaching about prescribed medications is important but falls under education and patient care rather than advocacy itself.

C. Collaboration with other team members is essential in providing holistic care but does not solely represent advocacy, which focuses more on the client's interests.

D. Supporting the client's needs is the core of advocacy, as it involves standing up for the client's rights, preferences, and well-being within the healthcare system.

A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.

B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.

C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.

D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.

A. Inserting an indwelling urinary catheter can be performed by licensed practical nurses (LPNs) under the supervision of an RN, so this task does not need to be reassigned.

B. Administering heparin subcutaneously is a task that can be performed by LPNs, so it does not require reassignment to an RN.

C. Suctioning a client's new tracheostomy is a more complex procedure that requires advanced skills and assessment, making it appropriate for an RN rather than an LPN.

D. Classifying a pressure ulcer is a task that can be done by both RNs and LPNs, so it does not need to be reassigned.

A. Smoke alarm batteries should be changed at least once a year, not every 2 years, so this statement reflects a misunderstanding of fire safety recommendations.

B. Spraying the extinguisher from side to side at the base of the fire is the correct technique for using a fire extinguisher, indicating the client understands proper fire safety.

C. Attempting to extinguish a fire before calling the fire department can be dangerous; the client should call for help first if the fire is large or spreading.

D. A Class A extinguisher is suitable for ordinary combustibles like wood and paper, but for electrical fires, a Class C extinguisher should be used, indicating a misunderstanding of fire extinguisher types.

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.

B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.

C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.

D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

A. QD (every day) is not an approved abbreviation due to the potential for misinterpretation, so it should not be used.

B. HS (at bedtime) is also not recommended as it can be confused with "half-strength," so it is not an approved abbreviation.

C. SQ (subcutaneous) is not commonly used in current practice as abbreviations may lead to errors; the term should be written out as "subcut" or "subcutaneously."

D. PO (by mouth) is an accepted and approved abbreviation used to indicate that a medication is to be taken orally, making it the correct choice for inclusion in the in-service.

A. While it's a good idea to rotate nonperishable food items to ensure freshness, the recommendation is typically to check them periodically rather than replace them annually, making this statement less accurate for disaster preparedness.

B. Having a backup supply of nonprescription medications is beneficial, but this is not a primary recommendation for disaster preparedness and may not specifically apply to all older adults.

C. The standard recommendation is to stock at least 1 gallon of water per person per day, not 2 liters, which is less than the recommended amount for hydration and other needs during emergencies.

D. Gathering enough supplies to last for 2 weeks is an essential component of disaster preparedness, especially for older adults who may have specific health needs and may not have easy access to supplies during a disaster.

A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.

B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.

C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.

D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.

B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.

C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.

D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.

A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.

B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.

C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.

D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.

A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.

B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.

C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.

D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.

A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.

B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.

C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.

D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.

A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.

B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.

C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.

D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.

A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.

B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.

C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.

D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.

A. Logging the previous user out of the system immediately ensures the client's health information is no longer visible, protecting the client's privacy according to HIPAA guidelines.

B. Offering to conduct an in-service on client confidentiality is a proactive measure but does not address the immediate privacy issue.

C. Reporting the incident to the charge nurse is appropriate but does not prevent unauthorized viewing of the client's information immediately.

D. Completing an incident report is necessary to document the breach, but it should occur after protecting the client’s privacy by logging out.

A. Investigating home care services covered by insurance is not the primary focus of a nurse preparing for an interprofessional meeting.

B. Developing a nutritional teaching plan, while beneficial, is more specific to nursing care and may not require input from the entire interprofessional team.

C. Creating a collaborative plan of care is a goal of the meeting itself rather than an individual preparation task.

D. Collecting data on the client’s required assistance level provides valuable input on the client’s current functional status, enabling a more comprehensive team discussion and planning for appropriate interventions.

A. Selecting an intervention is a subsequent step and should be informed by the baseline data on infection rates.

B. Incorporating the change into daily practice is necessary later in the process, once a specific intervention has been chosen and planned.

C. Determining if the change has lowered the infection rate is part of the evaluation phase, following the implementation of interventions.

D. Identifying current infection rates provides baseline data, which is essential for measuring the effectiveness of future interventions. Without this data, it is impossible to determine whether any implemented changes result in improvement.

A. Difficulty swallowing (dysphagia) is the priority because it increases the risk of aspiration, which can lead to aspiration pneumonia, a serious and potentially life-threatening complication for clients with Parkinson's disease.

B. Insomnia, while impacting quality of life, is not as immediately life-threatening as aspiration risk.

C. Needing additional help to stand reflects disease progression but does not carry the immediate risk of a life-threatening complication.

D. Difficulty dressing also indicates disease progression but does not pose an immediate danger to the client’s health.

A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.

B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.

C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.

D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.

A. Consulting the ethics committee is unnecessary at this stage, as there is no ethical dilemma in arranging social support services.

B. Suggesting a discharge delay is premature and may not be feasible; alternative support should be considered first.

C. Long-term care facility placement is a more permanent solution and may not align with the client’s needs or preferences.

D. Recommending a referral to social services is appropriate as social services can help arrange post-discharge support, including home health services or community resources, ensuring a safe transition home.

A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.

B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.

C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.

D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.