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 D
Explanation
Choice A rationale
Restlessness, also known as akathisia, is not a typical expected adverse effect of ondansetron. Ondansetron primarily acts as a selective 5-HT3 receptor antagonist, blocking serotonin's emetogenic effects in the chemoreceptor trigger zone and gastrointestinal tract. Common adverse effects are generally mild, including headache, constipation, or diarrhea, with neurological effects like restlessness being rare and atypical for this drug's primary mechanism.
Choice B rationale
Ondansetron should be administered prophylactically, typically 30 minutes *before* chemotherapy, to achieve optimal antiemetic effect. Its mechanism involves blocking serotonin receptors that, when activated by chemotherapy, trigger nausea and vomiting. Pre-emptive administration ensures therapeutic drug levels are present to counteract the emetogenic stimuli effectively before their onset.
Choice C rationale
Acute nausea and vomiting associated with chemotherapy can persist for significantly longer than 12 hours, often lasting for 24 to 48 hours or even longer depending on the specific chemotherapeutic agent and its emetogenic potential. The duration of emesis is highly variable and directly related to the drug's pharmacokinetic profile and the extent of serotonin release.
Choice D rationale
If nausea persists despite ondansetron administration, it indicates an inadequate antiemetic response, likely due to the complex neurochemical pathways involved in chemotherapy-induced nausea and vomiting. This often necessitates a multi-modal approach, involving the addition of other antiemetic agents like corticosteroids (e.g., dexamethasone) or neurokinin-1 receptor antagonists (e.g., aprepitant) to target different emetogenic pathways for more complete symptom control.
Correct Answer is B
Explanation
Choice A rationale
Disulfiram is an aldehyde dehydrogenase inhibitor used in the treatment of chronic alcoholism. It works by blocking the metabolism of ethanol, leading to the accumulation of acetaldehyde, which produces unpleasant physical reactions when alcohol is consumed. It has no pharmacological effect on benzodiazepine overdose.
Choice B rationale
Flumazenil is a competitive benzodiazepine receptor antagonist that rapidly reverses the sedative and other central nervous system effects of benzodiazepine overdose. It acts by binding to the gamma-aminobutyric acid (GABA) receptor complex, thereby displacing benzodiazepines and restoring normal neurological function.
Choice C rationale
Naloxone is an opioid receptor antagonist primarily used to reverse opioid overdose. It competitively binds to opioid receptors, particularly mu receptors, thereby blocking the effects of opioid agonists and reversing respiratory depression and other opioid-induced central nervous system depression. It does not affect benzodiazepines.
Choice D rationale
Dantrolene is a direct-acting skeletal muscle relaxant primarily used in the treatment of malignant hyperthermia and spasticity. It works by interfering with calcium release from the sarcoplasmic reticulum in muscle cells, reducing muscle contraction. It has no role in reversing benzodiazepine overdose.
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