A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

Fill out an incident report.

Report the incident to the nurse manager.

Notify the provider.

Measure the client's vital signs.

Answer and Explanation

The Correct Answer is D

A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.

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Correct Answer is C

Explanation

A. 0.45% saline. This is a hypotonic solution, which may be used later in diabetic ketoacidosis (DKA) management, but it is not appropriate for initial fluid resuscitation as it does not rapidly expand intravascular volume.
B. NPH insulin. NPH is an intermediate-acting insulin and is not used for continuous infusion. In DKA, rapid insulin correction is needed, typically with a short-acting insulin like regular insulin.
C. 0.9% normal saline. This isotonic fluid is the first-line choice for fluid replacement in clients with DKA. It helps restore circulating volume and correct dehydration quickly, which is a critical initial intervention.
D. Glargine insulin. Glargine is a long-acting insulin and not suitable for IV infusion. DKA requires the use of short-acting insulin (e.g., regular insulin) administered via IV infusion to correct hyperglycemia and acidosis.

A. Calories B. Folate C. Calcium D. Protein

Correct Answer is B

Explanation

A. Calories. Significant increases in caloric intake are not necessary during the first trimester. Most women do not require additional calories until the second and third trimesters, when fetal growth accelerates.
B. Folate. Folate (or folic acid) is crucial during early pregnancy, particularly in the first trimester, to prevent neural tube defects such as spina bifida. Women are advised to increase folate intake before conception and during early pregnancy.
C. Calcium. Calcium needs increase later in pregnancy when the fetus's bone development intensifies. While important throughout pregnancy, calcium is not the most critical nutrient to increase specifically in the first trimester.
D. Protein. Protein is essential for fetal growth, but increased protein needs become more important in the second and third trimesters when fetal tissue development peaks. Early pregnancy focuses more on folate supplementation for neural development.

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A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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