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 D
Explanation
Choice A rationale
High fever in the early morning is not a typical finding in pulmonary tuberculosis. TB patients may experience low-grade fevers, but high fevers are less common and usually occur in the evening or at night.
Choice B rationale
Fatigue is a common symptom of pulmonary tuberculosis. TB is a chronic infectious disease that can cause prolonged periods of fatigue and weakness due to the body’s ongoing immune response to the infection.
Choice C rationale
Increased appetite is not a typical finding in pulmonary tuberculosis. TB patients often experience a loss of appetite and unintentional weight loss due to the systemic effects of the infection.
Choice D rationale
Night sweats are a classic symptom of pulmonary tuberculosis. TB patients often experience drenching night sweats as a result of the body’s immune response to the infection. This symptom, along with chronic cough and weight loss, is a key indicator of TB.
Correct Answer is B
Explanation
Choice A rationale
Zucchini is not a significant source of calcium and would not be recommended for increasing calcium intake to reduce the risk of osteoporosis.
Choice B rationale
Collards are a good source of calcium and are recommended for clients at risk for osteoporosis. They provide a substantial amount of calcium, which is essential for bone health.
Choice C rationale
Potatoes are not a significant source of calcium and would not be recommended for increasing calcium intake.
Choice D rationale
Carrots are not a significant source of calcium and would not be recommended for increasing calcium intake.
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