A nurse is preparing to report a medication error to the nurse manager.

What is the most appropriate action for the nurse to take?

Document the error in the client's medical record and the incident report.

Notify the client's physician and the risk management department.

Explain the error to the client and apologize sincerely.

Wait until the end of the shift to report the error.

Answer and Explanation

The Correct Answer is A

Document the error in the client's medical record and the incident report.

Rationale: The nurse should document the error in both the client's medical record and the incident report, as this is part of the legal and ethical responsibility of the nurse. The documentation should include the facts of what happened, what actions were taken, and the client's response.

Incorrect options:

B) Notify the client's physician and the risk management department. - This is not the most appropriate action, as the nurse should first report the error to the nurse manager, who will then decide who else needs to be notified and how to proceed with further investigation and follow-up.

C) Explain the error to the client and apologize sincerely. - This is not the most appropriate action, as the nurse should first ensure that the client is safe and stable, and then consult with the nurse manager and the legal department before disclosing the error to the client. The nurse should also avoid admitting fault or liability, as this could have legal implications.

D) Wait until the end of the shift to report the error. - This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.

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Correct Answer is C

Explanation

Nuchal rigidity

Rationale: Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and indicates inflammation of the meninges, the membranes that cover the brain and spinal cord. Kernig's sign is a test that involves flexing the client's hip and knee at 90 degrees and then attempting to straighten the leg. A positive Kernig's sign is when the client experiences pain or resistance in the hamstring muscles, indicating meningeal irritation.

Incorrect options:

A) Fever - This is a nonspecific sign of infection and inflammation and does not indicate meningitis specifically.

B) Headache - This is a common symptom of meningitis, due to the increased intracranial pressure caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

D) Photophobia - This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

A. To prevent hypoglycemia during fasting B. To prevent lactic acidosis due to contrast dye C. To prevent hyperglycemia due to stress response D. To prevent nephrotoxicity due to dehydration

Correct Answer is B

Explanation

To prevent lactic acidosis due to contrast dye

Rationale: Metformin is an oral antidiabetic agent that lowers blood glucose levels by decreasing hepatic glucose production and increasing peripheral glucose uptake. However, metformin can cause lactic acidosis, a rare but serious condition that occurs when lactate accumulates in the blood faster than it can be metabolized. Lactic acidosis can be triggered by contrast dye used for radiographic procedures, such as colonoscopy, especially in clients who have renal impairment or dehydration. Therefore, metformin should be discontinued 48 hours before and after any procedure that involves contrast dye.

Incorrect options:

A) To prevent hypoglycemia during fasting - This is not the rationale for discontinuing metformin, as metformin does not cause hypoglycemia by itself. However, the client may need to adjust the dose of other antidiabetic medications or insulin to prevent hypoglycemia during fasting.

C) To prevent hyperglycemia due to stress response - This is not the rationale for discontinuing metformin, as metformin does not cause hyperglycemia by itself. However, the client may need to monitor blood glucose levels more frequently and report any signs of hyperglycemia to the provider.

D) To prevent nephrotoxicity due to dehydration - This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.

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A nurse is preparing to report a medication error to the nurse manager. What is the most appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with suspected meningitis. Which assessment finding should alert the nurse to perform a Kernig's sign test?

Correct Answer is C

Explanation

A client who has diabetes mellitus is scheduled for a colonoscopy. The nurse instructs the client to stop taking metformin 48 hours before and after the procedure. What is the rationale for this instruction?

Correct Answer is B

Explanation

A nurse is receiving a telephone order from a physician for a new medication for a client. Which action should the nurse take to ensure accuracy and safety?

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A nurse is preparing to report a medication error to the nurse manager.

What is the most appropriate action for the nurse to take?