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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.Notifying the charge nurse is an important action, as it ensures that other team members are aware of the error and can support corrective actions. However, this is not the first action the nurse should take, as assessing the client’s condition takes priority.
B.Informing the provider about the error is essential to allow for any additional orders or corrective measures, such as treatments to mitigate adverse effects. However, the nurse should first assess the client for any changes in condition to report specific findings to the provider if an intervention is needed.
C.Assessing the client’s condition is the first priority when a medication error is discovered. This action helps determine whether the incorrect dose has affected the client, allowing the nurse to provide immediate care if needed.
D.Completing an incident report is necessary to document the error, allowing the facility to review and address any procedural gaps. However, completing the report is not an immediate action in terms of client safety and should occur after assessing the client and notifying the necessary parties.
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.
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