What should the nurse do if they find a medication cup at the bedside with no record of administration?

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When a nurse discovers a medication cup at the bedside with no record of administration, the appropriate action is to document the missed medication administration. This documentation is vital for several reasons.

Firstly, it ensures accurate and comprehensive medical records, which are essential for maintaining continuity of care and allowing other healthcare providers to be informed about the patient's treatment. Documenting the missed administration also serves as a legal record of the incident and protects the nurse and facility from potential liability.

Additionally, by documenting the missed administration, the nurse can facilitate any necessary follow-up actions, such as determining if the medication needs to be given at a later time and assessing the impact on the patient’s condition. It also allows for evaluation of adherence to medication protocols, which could lead to improvements in nursing practices and patient safety.

The other options would not provide the same level of accountability and continuity of care; simply discarding the medication ignores the need for thorough documentation, while informing only the charge nurse may not address the need for treating the patient effectively. Notifying the client about the missed dose is important for transparency but does not substitute for the necessity of proper documentation in the patient's medical record.

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