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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
- Volume = 500 mg/ 330 mg/mL
- Volume≈1.5mL
Therefore, the nurse should administer approximately 1.5 mL per dose of cefazolin 500 mg IM.
Correct Answer is ["38"]
Explanation
To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula:
Flow Rate (gtt/min)=(Volume (mL)/Time (min)) × Drop Factor (gtt/mL)
In this case:
Flow Rate = (150 mL/hr / 60 min/hr) × 15 gtt/mL
Flow Rate=37.5gtt/min
Therefore, the nurse should set the IV flow rate to deliver approximately 38 gtt/min for the dextrose 5% in water IV infusion at 150 mL/hr, rounded to the nearest whole number.
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