Question

A nurse is caring for a client who received 0.9% sodium chloride 1L over 4 hours instead of 8 hours as prescribed. What information should the nurse enter as a complete documentation of the incident?

a. Client's response to the error
b. Time and rate of the incorrect infusion
c. Nurse's rationale for the mistake
d. Client's understanding of the error

Answer 1

A nurse should document the client's response, time, and rate of the incorrect infusion of 0.9% sodium chloride and details of the incident without attributing blame or the client's understanding of the error.

Step-by-step explanation:

When a nurse is caring for a client who received 0.9% sodium chloride 1L over 4 hours instead of the prescribed 8 hours, the nurse should document several key pieces of information to ensure a complete report of the incident. these include:

• Client's response to the error: Observations of any adverse effects or lack thereof as a result of the accelerated infusion.
• Time and rate of the incorrect infusion: Specific details about when the infusion was started and ended, as well as the rate at which it was administered.
• Documentation of the incident: A factual recount of the event without placing blame, including any immediate actions taken to mitigate the error.

It's important to note that entering the nurse's rationale for the mistake or the client's understanding of the error are not appropriate for the documentation. The focus should be on factual evidence and clinical observations.