A nurse identifies that a client has received a double dose of a medication in error. Which of the following actions should the nurse take first?

Complete an incident report about the occurrence.

Check the client's vital signs.

Notify the charge nurse of the error.

Document the facts of the incident in the nurse's notes.

Answer and Explanation

The Correct Answer is B

A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.

B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.

C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.

D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.

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Correct Answer is C

Explanation

A. Disinfect hands using an alcohol-based waterless antiseptic:

While alcohol-based hand sanitizers are effective against many germs, including bacteria, they may not be as effective against C. difficile. Soap and water are preferable for hand hygiene in C. difficile cases because alcohol does not effectively kill the spores.

B. Wear an N95 respirator when caring for the client:

The primary mode of transmission for C. difficile is through the fecal-oral route, and respiratory precautions are not necessary. Standard precautions, including wearing gloves and gowns, are generally sufficient.

C. Use diluted bleach to clean soiled equipment:

This is the correct answer. Bleach is an effective disinfectant against C. difficile spores. It is recommended for cleaning surfaces and equipment that may be contaminated.

D. Provide a room with negative-pressure airflow:

Negative-pressure airflow rooms are typically reserved for airborne infections, and they are not necessary for C. difficile. Standard precautions, along with thorough cleaning and disinfection, are the key measures.

A. Administer the medication twice daily. B. Administer the medication as needed for pain. C. Administer the medication 2 hr after meals. D. Administer a loading dose of 100 mg PO E. Administer the medication with a snack

Correct Answer is E

Explanation

Administer the medication twice daily.

Incorrect. The prescription specifies TID (three times daily), not twice daily.

Administer the medication as needed for pain.

Incorrect. The prescription provides specific dosing instructions (100 mg now, then 50 mg TID with food), and it is not meant for administration as needed.

Administer the medication 2 hr after meals.

Incorrect. The prescription specifies that indomethacin should be taken with food, so administering it 2 hours after meals is not in accordance with the instructions.

Administer a loading dose of 100 mg PO.

Incorrect. The initial dose of 100 mg is not considered a loading dose but rather the first dose in the prescribed regimen.

Administer the medication with a snack.

Correct. The prescription indicates that indomethacin should be taken with food. Administering

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A nurse identifies that a client has received a double dose of a medication in error. Which of the following actions should the nurse take first?

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