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 B
Explanation
A. Hyperthyroidism: Hyperthyroidism is not an absolute contraindication to combination oral contraceptive (COC) use. While thyroid hormone levels should be monitored, estrogen-containing contraceptives generally do not exacerbate hyperthyroidism in otherwise stable clients.
B. Thrombophlebitis: A history of thrombophlebitis or thromboembolic disorders is a significant contraindication to COC use. Estrogen in COCs increases coagulation factors and the risk of venous thromboembolism, making use in clients with prior thrombotic events unsafe.
C. Diverticulosis: Diverticulosis does not increase the risk of complications from COCs, nor do COCs exacerbate this gastrointestinal condition. It is not considered a contraindication.
D. Hypocalcemia: Low serum calcium levels are unrelated to COC use. COCs do not significantly affect calcium metabolism, so hypocalcemia is not a contraindication to their use.
Correct Answer is A
Explanation
A. Prime the tubing with 0.9% sodium chloride: Blood products must be administered with 0.9% sodium chloride to prevent hemolysis. Priming the tubing with saline ensures compatibility and maintains patency, allowing safe and effective transfusion without compromising the integrity of red blood cells.
B. Attach a single-line administration set: Blood transfusions require a specialized Y-type or filtered tubing to reduce the risk of clots, debris, and air embolism. Using a single-line set without a filter could allow microaggregates to enter the circulation.
C. Use tubing that does not have a filter in the drip chamber: A filter is essential for removing clots, debris, and cellular aggregates from the blood product. Administering blood without a filter increases the risk of complications such as emboli and febrile reactions.
D. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for safe transfusion of blood products. A larger-bore catheter, typically 18–20 gauge, is recommended to allow adequate flow and prevent hemolysis or catheter rupture during transfusion.
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