A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first?

Measure the client's vital signs.

Complete an incident report.

Inform the nurse manager.

Call the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: Measuring the client's vital signs is the first action that the nurse should perform, as it helps to assess the client's condition and the possible effects of the medication error. The nurse should monitor the client's blood pressure, heart rate, and respiratory rate closely and report any changes or abnormalities to the provider.

Choice B reason: Completing an incident report is not the first action that the nurse should perform, as it does not address the client's immediate needs or safety. The nurse should complete an incident report after providing care to the client and documenting the medication error in the client's record. The incident report should include the facts of the error, the actions taken, and the outcome of the client.

Choice C reason: Informing the nurse manager is not the first action that the nurse should perform, as it does not provide any intervention or treatment for the client. The nurse should inform the nurse manager after measuring the client's vital signs and calling the provider. The nurse manager can offer support and guidance to the nurse and help with the follow-up actions.

Choice D reason: Calling the provider is not the first action that the nurse should perform, as it does not give the nurse any information about the client's status or the severity of the error. The nurse should call the provider after measuring the client's vital signs and reporting the findings. The provider can order any necessary tests or treatments for the client.

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Correct Answer is D

Explanation

Choice A reason: I should discard personal health information documents in the trash before leaving the unit is not a correct statement, as it violates the client's privacy and the Health Insurance Portability and Accountability Act (HIPAA). I should shred or dispose of personal health information documents in a secure container or according to the facility's policy.

Choice B reason: I can post the client's vital signs in the client's room is not a correct statement, as it exposes the client's health information to unauthorized persons. I should keep the client's vital signs confidential and only share them with the client and the health care team.

Choice C reason: I can use another nurse's password as long as I log off after using the computer is not a correct statement, as it compromises the security and integrity of the electronic health record. I should use my own password and never share it with anyone else.

Choice D reason: I should encrypt personal health information when sending emails is a correct statement, as it protects the client's privacy and the HIPAA. I should use encryption or other secure methods when transmitting personal health information electronically.

A. "I cannot provide this information to you without your mother's consent." B. "What would you like to know about your mother's treatment?" C. "You will have to speak directly to your mother about her treatment." D. "I will ask your mother's primary care provider to speak with you."

Correct Answer is A

Explanation

Choice A reason: This is the correct response by the nurse. The nurse should respect the client's right to privacy and confidentiality and not disclose any information about the client's treatment plan without the client's consent. The nurse should also inform the adult child that they can ask their mother for permission to access her medical records.

Choice B reason: This is not the correct response by the nurse. The nurse should not ask the adult child what they want to know about the client's treatment, as this implies that the nurse is willing to share the information without the client's consent. The nurse should only answer the questions that the client has authorized the nurse to answer.

Choice C reason: This is not the correct response by the nurse. The nurse should not tell the adult child to speak directly to their mother about her treatment, as this may put pressure on the client to reveal information that she may not want to share. The nurse should respect the client's autonomy and decision-making regarding her treatment plan.

Choice D reason: This is not the correct response by the nurse. The nurse should not ask the client's primary care provider to speak with the adult child, as this may violate the client's privacy and confidentiality. The nurse should only involve the primary care provider if the client has given consent or if there is a legal or ethical obligation to do so.

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A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first?

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