A nurse is administering medications to a client and realizes the client received clonidine rather than the prescribed clonazepam.
After checking the client's blood pressure, which of the following actions should the nurse take first?
Notify the client's provider of the incident.
Complete an incident report describing the details of the incident.
Review the possible adverse effects of clonidine.
Administer clonazepam to the client as prescribed.
The Correct Answer is A
Choice A rationale
Notifying the client's provider is the first and most critical step. The provider needs to be immediately informed of the medication error, as they are responsible for assessing the client's current condition, determining the potential impact of the incorrect medication, and ordering necessary interventions or monitoring.
Choice B rationale
Completing an incident report is important for quality improvement and safety, but it should be done after the immediate safety of the client has been addressed and the provider has been notified. The priority is always patient well-being and clinical management.
Choice C rationale
While reviewing possible adverse effects is part of understanding the situation, the nurse's primary action should be to involve the prescribing authority. The provider can then provide specific guidance for monitoring and management based on the client's individual health status.
Choice D rationale
Administering clonazepam as prescribed should be done once the immediate risk from the clonidine has been assessed and managed, and the provider has given appropriate instructions. Giving the correct medication immediately without assessing the impact of the error could be premature or harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An INR (International Normalized Ratio) of 4.0 indicates that the client's blood is much thinner than the therapeutic range for most conditions (usually 2.0-3.0 for warfarin). This significantly increases the risk of bleeding. Vitamin K is the antidote for warfarin because it is essential for the synthesis of clotting factors (II, VII, IX, X) in the liver. Administering vitamin K reverses the anticoagulant effect of warfarin, reducing the risk of hemorrhage by promoting the production of functional clotting proteins.
Choice B rationale
Protamine sulfate is the antidote for heparin. It works by forming a stable ion pair with heparin, neutralizing its anticoagulant effects. It has no effect on the anticoagulant properties of warfarin, which acts by inhibiting vitamin K epoxide reductase, an enzyme crucial for the regeneration of active vitamin K necessary for clotting factor synthesis. Therefore, protamine is not indicated for warfarin overdose.
Choice C rationale
Calcium gluconate is used to treat hypocalcemia and magnesium toxicity. Calcium plays a vital role in numerous physiological processes, including bone health and muscle function, and is essential for blood coagulation. However, it does not directly counteract the effects of warfarin, which targets vitamin K-dependent clotting factors, and is not the appropriate antidote for an elevated INR.
Choice D rationale
Epinephrine is a potent vasoconstrictor and bronchodilator used in anaphylaxis, cardiac arrest, and severe asthma. It acts on alpha and beta-adrenergic receptors, leading to increased heart rate, blood pressure, and bronchodilation. It has no role in reversing the anticoagulant effects of warfarin and is not indicated for managing an elevated INR.
Correct Answer is C
Explanation
Choice A rationale
Constipation is not a commonly associated adverse effect of ciprofloxacin. Fluoroquinolones primarily impact gastrointestinal motility through alterations in gut flora and direct irritation, often leading to diarrhea or abdominal discomfort rather than constipation. The drug's mechanism does not typically promote slowed bowel movements or decreased peristalsis.
Choice B rationale
Weight gain is not a typical adverse effect of ciprofloxacin. Fluoroquinolones do not directly influence metabolic pathways or fluid retention in a manner that would lead to increased body mass. Adverse effects are usually related to gastrointestinal disturbances, neurological effects, or musculoskeletal issues.
Choice C rationale
Phototoxicity is a significant adverse effect of ciprofloxacin, a fluoroquinolone antibiotic. This occurs due to the drug's ability to absorb ultraviolet radiation, leading to a photochemical reaction that damages skin cells. This damage can manifest as severe sunburn, blistering, or rash upon exposure to sunlight.
Choice D rationale
Bradycardia is not a recognized adverse effect of ciprofloxacin. While some antibiotics can rarely affect cardiac conduction, ciprofloxacin's primary cardiovascular concerns relate more to QT prolongation and potential arrhythmias, not typically a decrease in heart rate. Its mechanism does not directly depress sinoatrial node function.
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