A nurse inadvertently administers an incorrect medication to a client. Which action should the nurse take first?
Inform the unit supervisor.
Notify the health care provider.
Document the error in the client’s medical record.
Record the error on the appropriate quality improvement report.
The Correct Answer is B
Notify the health care provider. The nurse should take this action first because the provider can prescribe appropriate interventions to prevent or minimize harm to the client.
The nurse should also inform the unit supervisor, document the error in the client’s medical record, and record the error on the appropriate quality improvement report, but these are not the priority actions.
Choice A is wrong because informing the unit supervisor is not the most urgent action. The supervisor can provide support and guidance to the nurse, but cannot prescribe interventions for the client.
Choice C is wrong because documenting the error in the client’s medical record is not the most urgent action.
The nurse should document the error after notifying the provider and assessing the client. Documentation should include the medication name, dose, route, time, client’s response, and actions taken.
Choice D is wrong because recording the error on the appropriate quality improvement report is not the most urgent action.
The nurse should record the error after notifying the provider and assessing the client. The report should include a factual description of what happened and what was done.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.
Choice A is wrong because maximum benefits do not occur within the first five minutes.
It takes time for heat to penetrate the tissues and cause vasodilation.
Choice C is wrong because the heat should not be left in place for at least one hour to be effective.
This can lead to burns, increased edema, and decreased blood flow.
Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.
This can cause severe tissue damage, infection, and necrosis.
Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).
The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.
The skin should also be inspected for signs of erythema, blisters, or burns.
Correct Answer is D
Explanation
Diminished breath sounds in a client admitted with pneumonia. This is because diminished breath sounds indicate a worsening of the respiratory condition and a possible complication of pneumonia, such as atelectasis or pleural effusion.
The healthcare provider should be notified immediately to assess the client and order appropriate interventions.
Choice A is wrong because a report of joint pain by a client who recently started taking arthritis medication is not an urgent finding.
Joint pain is a common symptom of arthritis and may take some time to improve with medication.
The nurse should monitor the client’s pain level and administer analgesics as prescribed.
Choice B is wrong because report of decreased appetite and difficulty sleeping is not an immediate concern.
These are nonspecific symptoms that may be related to stress, anxiety, depression, or other factors.
The nurse should explore the possible causes of these symptoms and provide emotional support and education to the client.
Choice C is wrong because a weight loss of two pounds in a client admitted to congestive heart failure is not a critical finding.
Weight loss may indicate a reduction of fluid retention, which is a desired outcome for clients with heart failure.
The nurse should monitor the client’s weight daily and report any significant changes to the health care provider.
Normal ranges for weight, appetite, sleep, joint pain, and breath sounds vary depending on the individual’s age, gender, height, activity level, medical history, and other factors.
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