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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B.
Choice A reason:
Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.
Choice B reason:
Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.
Choice C reason:
Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.
Choice D reason:
Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
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