A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
Report the incident to the nurse manager.
Measure the client's vital signs.
Fill out an incident report.
Notify the provider.
The Correct Answer is B
A. Report the incident to the nurse manager: Reporting to the nurse manager is important for institutional accountability and guidance, but it is not the immediate priority. The client’s safety must be addressed first.
B. Measure the client's vital signs: Assessing the client’s current condition, including vital signs, is the first action because it identifies any immediate physiologic effects of the medication error. This assessment guides subsequent interventions and determines the urgency of notifying the provider.
C. Fill out an incident report: Completing an incident report is required for documentation and quality improvement, but it is secondary to ensuring the client’s safety and assessing for adverse effects.
D. Notify the provider: The provider must be informed to determine medical interventions, but this step follows the initial assessment of the client to establish their current status and identify any immediate threats to safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
A. Lubricate the catheter with sterile saline: Lubrication reduces friction and trauma to the tracheal mucosa during insertion, facilitating smoother catheter advancement and minimizing irritation.
B. Insert the catheter until resistance is felt: The catheter is advanced gently until the first point of resistance, which indicates proximity to the carina or a main bronchus. This prevents excessive insertion that could injure airway structures.
C. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in): Withdrawing slightly before applying suction helps avoid direct trauma to the carina while still targeting secretions in the larger airways for effective clearance.
D. Rotate the catheter while suctioning: Rotating the catheter while applying suction maximizes removal of secretions from the trachea and bronchi while distributing suction forces evenly, reducing the risk of mucosal injury.
Correct Answer is D
Explanation
A. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers are used to assess fetal lie, presentation, and position. While important for assessment, they do not address acute maternal symptoms such as sudden nausea, which may indicate supine hypotensive syndrome.
B. Ask the client to increase her daily calcium intake: Calcium intake is unrelated to sudden nausea in a client at 36 weeks of gestation. Adjusting dietary calcium will not alleviate acute symptoms caused by maternal positional hypotension.
C. Administer propranolol IV to the client: Propranolol, a beta-blocker, is not indicated for sudden nausea associated with late-stage pregnancy. Its use could adversely affect maternal blood pressure and fetal heart rate without addressing the underlying cause.
D. Position the client on her side: Lying supine in late pregnancy can compress the inferior vena cava, reducing venous return and cardiac output, which may cause nausea, dizziness, or hypotension. Positioning the client on her left or right side alleviates vena caval compression and improves maternal perfusion and symptom relief.
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