A nurse is preparing to administer a medication to a client and discovers that the incorrect dose of medication was administered during the previous shift. Which of the following actions should the nurse take first?

Notify the charge nurse of the error.

Contact the provider.

Check the client for a change in condition.

Complete an incident report.

Answer and Explanation

The Correct Answer is C

A. Notifying the charge nurse is an important action, as it ensures that other team members are aware of the error and can support corrective actions. However, this is not the first action the nurse should take, as assessing the client’s condition takes priority.

B. Informing the provider about the error is essential to allow for any additional orders or corrective measures, such as treatments to mitigate adverse effects. However, the nurse should first assess the client for any changes in condition to report specific findings to the provider if an intervention is needed.

C. Assessing the client’s condition is the first priority when a medication error is discovered. This action helps determine whether the incorrect dose has affected the client, allowing the nurse to provide immediate care if needed.

D. Completing an incident report is necessary to document the error, allowing the facility to review and address any procedural gaps. However, completing the report is not an immediate action in terms of client safety and should occur after assessing the client and notifying the necessary parties.

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Correct Answer is D

Explanation

A. Medication administration record:

The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.

B. Standardized care plan:

A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.

C. 180 record:

The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.

D. Client care Kardex:

This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.

A. A client who reports experiencing short-term memory loss B. A client who is wearing urine-scented clothing C. A client who has fingernails that are discolored and broken D. A client who provides a detailed description of a recent fall at home

Correct Answer is B

Explanation

A. A client who reports experiencing short-term memory loss:

Memory loss is a common issue in older adults and does not necessarily indicate elder abuse. While it is a concern that should be addressed, it may not be related to abuse unless there are specific circumstances suggesting mistreatment.

B. A client who is wearing urine-scented clothing.

Wearing urine-scented clothing can be indicative of neglect, which is a form of elder abuse. Neglect occurs when the basic needs of an older adult, such as hygiene and cleanliness, are not adequately met. The nurse should report this finding to the case manager so that appropriate interventions and assessments can be made to address the potential abuse or neglect.

C. A client who has fingernails that are discolored and broken:

Fingernail issues can have various causes, including medical conditions or self-neglect. Discolored and broken fingernails alone may not be conclusive evidence of elder abuse, and further assessment is needed to determine the cause.

D. A client who provides a detailed description of a recent fall at home:

While falls are a concern, providing a detailed description of a fall is not necessarily indicative of elder abuse. Falls can occur for various reasons, and additional assessment is needed to determine the circumstances surrounding the fall and whether abuse or neglect is involved.

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A nurse is preparing to administer a medication to a client and discovers that the incorrect dose of medication was administered during the previous shift. Which of the following actions should the nurse take first?

Nursing Test Bank

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