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 A

Explanation

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

A. Beneficence B. Fidelity C. Autonomy D. Justice

Correct Answer is C

Explanation

A. Beneficence:

Beneficence is the ethical principle of doing good or promoting the well-being of the patient. In this scenario, the nurse is respecting the client's autonomy rather than actively promoting a specific course of action.

B. Fidelity:

Fidelity refers to the principle of being faithful or keeping promises. While being truthful and honest with the client is important, the nurse's response is primarily addressing the client's autonomy.

C. Autonomy:

This is the correct answer. Autonomy is the ethical principle that emphasizes the individual's right to make decisions about their own care, including the right to refuse treatment. The nurse's response acknowledges and respects the client's autonomy in deciding to discontinue enteral feedings.

D. Justice:

Justice pertains to fairness and equitable distribution of resources. It is not the primary ethical principle being demonstrated in this scenario, as the focus is on the individual's right to make a decision about their own care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has a terminal illness and states that they wish to discontinue their enteral feedings. The nurse responds by saying "You have a right to refuse treatment." This response by the nurse demonstrates which of the following ethical principles?

Correct Answer is C

Explanation

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