Question

The nurse discovers a solution of Heparin IV infusing on a client when D5W is ordered. What is the appropriate initial action? A. Remove the Heparin and hang D5W B. Notify the physician about the incident C. Inform the charge nurse of the error D. Complete an occurrence report

Short answer

Answer: A. Remove the Heparin and hang D5W

Step-by-step solution

Identify the problem

The problem in this exercise is that a client is receiving an infusion of Heparin IV instead of the ordered D5W. This is a medication error that needs to be addressed immediately, as it might have serious consequences for the patient.

Analyze the options

Before deciding on the initial action, let's review the options. A. Remove the Heparin and hang D5W - This action will correct the medication error, but it does not address the proper procedure of reporting and managing such incidents. B. Notify the physician about the incident - Reporting the error to the physician is an essential part of the procedure. However, it might not be the most immediate action. C. Inform the charge nurse of the error - Communicating the error to the charge nurse is a crucial part of the procedure as well. D. Complete an occurrence report - While this action is also significant, it is not considered immediate.

Determine the priority in this situation

In this scenario, the priority is to correct the medication error, ensure patient safety, follow proper procedures, and report the incident to the appropriate personnel.

Choose the appropriate initial action

As the priority is to correct the error and ensure patient safety, the appropriate initial action in this case is: A. Remove the Heparin and hang D5W In conclusion, the correct answer is A. Remove the Heparin and hang D5W. This is the most immediate action to ensure patient safety and correct the medication error. Subsequently, the nurse should notify the physician, inform the charge nurse, and complete an occurrence report regarding the incident.

Key concepts

Medication Administration

Medication administration is a critical nursing responsibility because it directly affects patient care. In the context of the exercise where Heparin was administered instead of D5W, it's essential to recognize this as a medication error. The immediate response is to rectify this by stopping the incorrect infusion and starting the correct one.

The steps in medication administration typically include verification of the doctor's order, checking the patient's medication record, correctly identifying the patient, and then administering the medication using the 'Five Rights': the right patient, the right drug, the right dose, the right route, and the right time.

Double-Checking Before Administration

Ensure that the label on the medication is checked three times: when pulling it from the shelf or drawing up, before returning it if unused, and before administering it to the patient.

Documentation

After administering the medication, document the administration details, including time and any observed effects, which is crucial for continuity of care and for legal and professional reasons.

Patient Safety

Patient safety is paramount in healthcare settings, and the exercise underscores the importance of immediate action to prevent harm. A cornerstone principle is preventing medication errors, which can lead to serious adverse outcomes for patients. When such an error is identified, the nurse's first obligation is to stabilize the situation and ensure that the patient is not at risk.

Error Prevention Strategies

Key strategies include employing barcode medication administration (BCMA), encouraging a culture of safety where nurses feel comfortable reporting errors or near misses, and participating in regular training sessions. Nurse education programs and continuous professional development initiatives play a significant role in maintaining high safety standards.

Nursing Protocols

Nursing protocols serve as guidelines to ensure consistent and safe patient care. They encompass step-by-step procedures for tasks like medication administration and how to respond when errors occur, as observed in the given exercise. The protocols would dictate that after correcting the administration error, subsequent reporting is essential to prevent future incidents.

Adherence to Protocols

Standard protocols include checking medication orders, reporting errors without delay, and documenting every step taken after an error has been identified. This structured approach contributes to a culture of safety and accountability, leading to improved patient outcomes.

NCLEX-PN Exam Preparation

Preparing for the National Council Licensure Examination for Practical Nurses (NCLEX-PN) involves thorough knowledge of nursing fundamentals and safety protocols. The exam assesses your understanding of health promotion and maintenance, safe and effective care environments, psychosocial integrity, and physiological integrity.

Study and Practice

Prospective nurses should familiarize themselves with the types of questions that may appear on the exam, including prioritization and management of care, which directly relate to medication administration and safety. Engaging with practice exercises, such as the one provided, ensures that practical decision-making skills are honed, which is essential for exam success and real-world nursing practice.