The client complains of pain, and tells the nurse that the last time he got pain medication, it was dark outside

Question

The nurse checks the medical record and sees that the day shift nurse documented administering an injection of narcotic analgesics twice during the day. The client's wife says she was with him all day and he never received an injection. The nurse's priority action is to: 1. Call the Board of Nursing to notify them of falsification of records.
2. Notify the nursing supervisor immediately of the situation.
3. Call the day shift nurse to ask if the medication was actually given.
4. Complete an incident report.

Answer 1

2
Rationale 1: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to determine what actually occurred. The nurse should not jump to conclusions based on a small amount of information, so the Board of Nursing should not be notified and an incident report should not be completed at this time. It is not the nurse's responsibility to call the day shift nurse.