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    ATI PN Comprehensive Predictor 2023 Proctored Exam 4

    A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

    Explanation & Rationale

    Incident report When a nurse makes a medication error, such as administering an incorrect dose or an extra dose, it is important to document the incident in an incident report. Incident reports are confidential documents that provide a record of the event, facilitate communication among healthcare providers, and allow for further investigation and analysis to prevent future errors. Provider's progress notes in (option A) is incorrect. The provider's progress notes are typically used to document the provider's assessment, diagnosis, treatment plan, and progress of the client. Medication errors made by nursing staff are not typically documented in the provider's progress notes. Controlled substance inventory record in (option C) is incorrect. The controlled substance inventory record is used to track the administration and use of controlled substances. It may not be the appropriate location to document a medication error. However, it is important to follow institutional policies regarding the documentation of medication errors involving controlled substances. Nursing care plan in (option D) is incorrect. The nursing care plan is a document that outlines the nursing diagnoses, goals, interventions, and evaluations related to the client's care. While medication administration may be a part of the nursing care plan, documenting a medication error in this location is not the standard practice. Incident reports are specifically designed for reporting and documenting errors or incidents that occur during client care.

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