After the 0700 report, the day shift nurse notices that a patient has a 0730 dose of insulin due and goes to the automated dispensing machine to retrieve the insulin. The nurse sees that the night shift nurse had removed the 0730 dose of insulin, but the medication administration record has not been signed by the nurse. The patient is confused and says she thinks she took it. The patient's blood glucose level is 142 mg/dL. What will the day shift nurse do?

Choice A rationale Administering a medication when there is a strong possibility the patient has already received it could lead to an overdose. The automated dispensing machine's record indicates removal of the dose, and the patient's statement, despite her confusion, suggests she might have taken it. The nurse's primary responsibility is patient safety and preventing medication errors, which this action would violate. Choice B rationale This is the safest course of action. The medication was removed from the machine, and the patient states she thinks she took it. The night shift nurse's failure to sign the MAR is a documentation error, but the potential for a double dose is a serious safety concern. The nurse should hold the dose and investigate further before administering anything to prevent an iatrogenic event. Choice C rationale Notifying the provider for a new order is an unnecessary and premature step. The issue is not that the medication is unavailable or the order is incorrect. The immediate concern is whether the patient has already received the dose. Holding the medication and verifying the administration is the correct first step, and the provider would not be contacted unless there was a clinical reason to do so, such as if the blood glucose became dangerously high. Choice D rationale Giving the insulin and then monitoring the patient is dangerous. Administering an additional dose of insulin could cause a severe hypoglycemic event, especially in a confused patient. The blood glucose of 142 mg/dL is not critically high, so there is no immediate need for the insulin, and the risk of a medication error outweighs any perceived benefit of administering the medication immediately.