Question

A nurse is precepting a newly licensed nurse who is caring for four clients. The nurse should complete an incident report for which of the following actions by the newly licensed nurse?

1) Administering isosorbide mononitrate to a client who has a blood pressure of 82/60 mmHg
2) Administering digoxin to a client who has a heart rate of 92 bpm
3) Administering regular insulin to a client who has a glucose level of 250 mg/dL
4) Administering heparin to a client who has an activated partial thromboplastin time (aPTT) of 70 seconds

Answer 1

An incident report should be completed for the action of administering isosorbide mononitrate to a client with a low blood pressure of 82/60 mmHg, as this could cause harmful hypotension.The correct option is 1.

Step-by-step explanation:

An incident report should be completed for a newly licensed nurse who administers isosorbide mononitrate to a client who has a blood pressure of 82/60 mmHg. Isosorbide mononitrate is a medication that can lower blood pressure, and administering it to a patient with already low blood pressure could result in hypotension and is a potentially unsafe action that necessitates documentation and review.

The other actions listed, such as administering digoxin to a client with a heart rate of 92 bpm, regular insulin to a client with a glucose level of 250 mg/dL, or heparin to a client with an aPTT of 70 seconds, may be appropriate depending on the specific circumstances and provided they align with current medical guidelines and facility protocols.