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 A

Explanation

Choice A reason: An incident report is necessary when a client discovers that his dentures are missing. This situation involves a loss of personal property and could potentially lead to further complications, such as the client being unable to eat properly or experiencing distress. Documenting the incident ensures proper follow-up and resolution.

Choice B reason: While identifying a broken piece of equipment is important and should be addressed, it does not typically require an incident report unless the equipment failure has directly caused harm or posed a significant risk to a client or staff member. Reporting the issue through maintenance channels is usually sufficient.

Choice C reason: A disagreement between the nurse and the nursing supervisor about staffing is an internal issue that should be addressed through appropriate channels such as team meetings or discussions with management, rather than an incident report.

Choice D reason: A staff member not showing up for their assigned shift is a staffing issue that should be managed through scheduling and human resources processes. It does not typically warrant an incident report unless it directly leads to an adverse event affecting client care.

A. Client reports having intermittent mild headaches. B. Client reports some erectile dysfunction. C. Client reports having dyspnea and chest pain. D. Client reports having elevated liver function tests.

Correct Answer is C

Explanation

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

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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 is caring for several clients. For which of the following situations should the nurse complete an incident report?

Correct Answer is A

Explanation

The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

Correct Answer is C

Explanation

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?

The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?

The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?