A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
Notify the charge nurse.
Check the client’s vital signs.
Fill out an occurrence report according to institutional policy.
Document an objective description of what has happened in the client’s chart.
The Correct Answer is B
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: Determine the total dosage required. 100 mcg Step 2: Determine the dosage per tablet. 50 mcg per tablet Step 3: Calculate the number of tablets needed. 100 mcg ÷ 50 mcg/tablet = 2 tablets The nurse should administer 2 tablets.
Correct Answer is B
Explanation
Choice A rationale
Obesity is not a direct cause of renal calculi. However, it can be a risk factor due to associated conditions such as metabolic syndrome, diabetes, and hypertension, which can contribute to stone formation. Weight management and a healthy lifestyle can help reduce the risk of kidney stones.
Choice B rationale
Dehydration is a significant risk factor for the formation of renal calculi. When the body is dehydrated, the urine becomes concentrated, leading to the crystallization of minerals and the formation of stones. Adequate hydration is essential in preventing kidney stones by diluting the urine and reducing the concentration of stone-forming substances.
Choice C rationale
Iron deficiency is not associated with the formation of renal calculi. Iron deficiency primarily affects red blood cell production and can lead to anemia. It does not contribute to the crystallization of minerals in the urine or the formation of kidney stones.
Choice D rationale
Protein in the urine, or proteinuria, is not a direct cause of renal calculi. Proteinuria is often a sign of kidney damage or disease but does not lead to stone formation. The presence of protein in the urine should be evaluated to determine the underlying cause and appropriate treatment.
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