NCLEX Practice Test

The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time?

1. Document the incident in the nurse's employee file and review it with the unit manager

2. Follow institutional protocol for filing an incident or variance report

3. Instruct the nurse to notify the health care provider about the lack of pain relief

4. Report the incident to the hospital's ethics committee for evaluation

The correct answer is: Document the incident in the nurse's employee file and review it with the unit manager

The priority action for the charge nurse in this scenario is to ensure the safety and well-being of the client, while also addressing the concerns regarding potential medication misuse given the client’s history of drug abuse. Documenting the incident in the nurse's employee file and reviewing it with the unit manager allows for a formal acknowledgment of the nurse’s concerns about pain management and medication administration. This documentation is essential for tracking patterns of behavior in both the client and nursing care, providing necessary context for future care. Furthermore, it creates a record that can be utilized for quality assurance and training purposes, while ensuring that the nursing staff is aware of the complexities involved in managing patients with a history of substance abuse. Addressing the underlying issues without escalating the situation unnecessarily is vital, as further interventions can be tailored based on this documentation, ensuring that both the client’s pain and safety are prioritized effectively.