A nurse is preparing to administer medications to a client and notices the wrong medication was administered on the previous shift. Which of the following actions should the nurse take first after obtaining vital signs?
Complete an incident report.
Document the findings in the nurse’s notes.
Notify the nursing manager.
Inform the client’s provider.
The Correct Answer is D
A. Complete an incident report is necessary for documenting the error, but it should not be the first action. Immediate steps should focus on patient safety and addressing the error.
B. Document the findings in the nurse’s notes is important for maintaining accurate medical records, but it should follow the immediate actions taken to address the error.
C. Notify the nursing manager is important for internal reporting and addressing the error within the healthcare team, but it should not be the first action.
D. Inform the client’s provider is the first action the nurse should take. The provider needs to be informed immediately to assess the client’s condition, determine any necessary interventions, and prevent potential harm from the medication error.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diarrhea is not a common adverse effect of total parenteral nutrition (TPN). TPN is administered intravenously, bypassing the gastrointestinal tract, so it does not typically cause diarrhea.
B. Aspiration pneumonia is not associated with TPN, as TPN is delivered directly into the bloodstream and does not involve the respiratory system.
C. Electrolyte imbalance is a significant adverse effect of TPN. TPN solutions contain various electrolytes, and improper formulation or administration can lead to imbalances, which can cause serious complications such as cardiac arrhythmias, muscle weakness, and neurological issues.
D. Nausea is not commonly associated with TPN, as it bypasses the gastrointestinal tract. Nausea may occur due to other underlying conditions but is not a direct adverse effect of TPN.
Correct Answer is C
Explanation
A. “Call 911 if pain persists 30 minutes after taking one tablet” is incorrect. The client should call 911 if chest pain persists after taking three doses of nitroglycerin at 5-minute intervals, not 30 minutes.
B. “Take a tablet every 10 minutes until the pain subsides” is incorrect. The correct instruction is to take one tablet every 5 minutes, up to three tablets, and seek emergency help if the pain does not subside.
C. “Place the tablet under the tongue until dissolved” is correct. Sublingual nitroglycerin should be placed under the tongue to dissolve, allowing for rapid absorption and relief of angina.
D. “Store the tablets in a refrigerator in a plastic container” is incorrect. Nitroglycerin tablets should be stored at room temperature in their original glass container to maintain potency.
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