A nurse discovers that a client was administered an antihypertensive medication in error. What would be the priority action for the nurse to do first?

Call the provider.

Notify risk management.

Check the client's vital signs.

Complete an incident report.

Answer and Explanation

The Correct Answer is C

Choice A reason: Calling the provider is important, but it is not the immediate priority. Before contacting the provider, the nurse needs to assess the client's condition to provide accurate information about any potential adverse effects of the medication error.

Choice B reason: Notifying risk management is a necessary step in reporting the medication error, but it should be done after ensuring the client's safety and stability. Immediate patient assessment takes precedence.

Choice C reason: Checking the client's vital signs is the priority action because it allows the nurse to assess the client's current condition and identify any immediate adverse effects of the medication error. This information is critical for determining the appropriate next steps and ensuring the client's safety.

Choice D reason: Completing an incident report is essential for documenting the medication error, but it should be done after addressing the client's immediate needs and ensuring their safety. The nurse's first responsibility is to assess and manage the client's condition.

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Correct Answer is C

Explanation

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

A. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." B. "Mass casualty events do not require an increase in the number of staff that are needed." C. "A mass casualty event only occurs within the health care facility and could endanger staff." D. "An event is termed a mass casualty when it overwhelms local medical capabilities." E. "Mass casualty events may require the collaboration of many local agencies to handle the situation."

Correct Answer is ["A","B","C"]

Explanation

Choice A reason: This statement is incorrect because a mass casualty event refers to an incident that results in a large number of casualties, overwhelming the local healthcare system. A fight between visitors in the emergency department, although potentially serious, would not constitute a mass casualty event.

Choice B reason: This statement is incorrect because mass casualty events typically require a significant increase in the number of staff to manage the influx of patients and provide adequate care. Staffing levels are often augmented to ensure that the medical response can meet the demands of the situation.

Choice C reason: This statement is incorrect because mass casualty events are not limited to occurring within healthcare facilities. They can happen anywhere, such as at public events, natural disasters, or terrorist attacks, and involve a large number of casualties that overwhelm local medical resources.

Choice D reason: This statement is correct and does not indicate a need for further teaching. A mass casualty event is indeed characterized by overwhelming local medical capabilities, necessitating additional resources and support.

Choice E reason: This statement is correct and does not indicate a need for further teaching. Mass casualty events often require collaboration among multiple local agencies, such as emergency services, law enforcement, and healthcare providers, to effectively manage the situation.

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A nurse discovers that a client was administered an antihypertensive medication in error. What would be the priority action for the nurse to do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?

Correct Answer is C

Explanation

The nurse educator is educating new staff nurses about mass casualty events. Which statements by the new nurse indicate a need for further teaching? (Select All That Apply)

Correct Answer is ["A","B","C"]

Explanation

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