A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Complete an incident report.

Notify the nurse manager.

Call the client's provider.

Assess the client.

Answer and Explanation

The Correct Answer is D

A. While completing an incident report is important for documentation and quality improvement, it is not the immediate priority in the event of a medication error.

B. Notifying the nurse manager is a necessary step for reporting the error, but it should occur after ensuring the client's safety.

C. Calling the client's provider is essential to discuss the medication error and possible interventions, but the client's health and safety must be assessed first.

D. Assessing the client is the priority action to ensure the client’s safety and to identify any adverse effects resulting from the wrong medication. The nurse needs to determine the client's vital signs, level of consciousness, and any immediate symptoms related to the medication administered.

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Correct Answer is D

Explanation

A. Proceeding to measure the oral temperature immediately after the client has consumed ice chips can lead to an inaccurate reading due to the cooling effect of the ice.

B. Documenting that the nurse was unable to measure the client's temperature is unnecessary; it is possible to obtain an accurate measurement after a suitable waiting period.

C. Providing a sip of warm water will not resolve the issue of the ice chips affecting the temperature reading, as the nurse should still wait a longer period for accuracy.

D. Waiting 30 minutes after the client has consumed ice chips is the best practice, as it allows sufficient time for the oral cavity to return to a baseline temperature for an accurate measurement.

A. Perform range-of-motion (ROM) exercises at least two to three times daily. B. Auscultate breath sounds at least every 2 hr. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply anti-embolic stockings.

Correct Answer is B

Explanation

A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.

B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.

C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.

D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.

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A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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