A nurse recognizes they administered a medication over one hour when the order dictated the medication be given over 90 minutes. Which should be the first action performed by the nurse?
Prepare and administer the prescribed antidote.
Notify the charge nurse, the nurse manager, and the prescriber.
Assess the identify the presence of urgent safety issues
Complete an incident report detailing the error
The Correct Answer is C
A) Prepare and administer the prescribed antidote: Administering an antidote would only be appropriate if the medication error resulted in a harmful reaction that requires immediate reversal. Since the issue here is the timing of medication administration, it is more important to first assess the client for any immediate effects rather than administering an antidote, which might not be necessary at this stage.
B) Notify the charge nurse, the nurse manager, and the prescriber: While notifying the appropriate staff is crucial, the first action should be assessing the client for any safety concerns or complications resulting from the medication administration error. Immediate evaluation of the client's condition should take precedence over notification.
C) Assess and identify the presence of urgent safety issues: The first priority in this situation is to assess the client for any adverse effects or reactions due to the medication being administered too quickly. This could include monitoring for signs of toxicity, adverse reactions, or changes in vital signs that may indicate a potential risk to the client’s health. Once the client's status is assessed, further actions such as notifying other staff or completing an incident report can follow.
D) Complete an incident report detailing the error: While documenting the error in an incident report is necessary, this should not be the first step. The immediate priority is to ensure the client’s safety by assessing their condition, as an error in the timing of medication administration may result in unwanted side effects or complications that need to be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Low albumin: This factor has the most impact on the pharmacokinetic phase of distribution. Albumin is a key protein in the blood that binds to many medications. When albumin levels are low, fewer drug molecules will be bound, leading to an increased concentration of free (unbound) drug in the bloodstream. This can result in enhanced drug effects or toxicity, as the unbound drug is pharmacologically active and more readily able to cross cell membranes.
B) Renal disease: While renal disease can impact drug elimination and excretion, it does not have as direct an effect on the distribution phase of pharmacokinetics. Renal function primarily affects the clearance of drugs from the body rather than how the drug is distributed within the tissues.
C) Hepatic disease: Hepatic disease can affect the metabolism of drugs and their clearance, but it does not directly affect the distribution phase. While the liver is involved in metabolizing drugs, it is the ability to clear or process the drug that is most influenced, rather than its distribution to tissues.
D) An elevated gastric pH: Elevated gastric pH (which can occur with antacid use or in certain conditions) can affect the absorption of some medications but has minimal direct impact on the distribution phase of pharmacokinetics. Distribution is primarily concerned with how a drug moves from the bloodstream into tissues, and this is more influenced by factors like blood flow, protein binding, and the drug's lipophilicity, rather than the pH of the stomach.
Correct Answer is A
Explanation
A) 90 degrees: For intramuscular (IM) injections, including in the ventrogluteal site, the needle should be inserted at a 90-degree angle to ensure that the medication is deposited deep into the muscle tissue. This angle allows the needle to penetrate the skin and subcutaneous tissue directly into the muscle where it can be absorbed efficiently. The ventrogluteal site, being a large and well-muscled area, is ideal for IM injections because it is less likely to cause damage to nerves or blood vessels, and a 90-degree angle ensures proper placement of the medication.
B) 45 degrees: A 45-degree angle is commonly used for subcutaneous injections which go into the fatty tissue just beneath the skin. This angle ensures that the medication is delivered into the correct layer of tissue, allowing for slow absorption. However, when administering an IM injection, a 45-degree angle would not be deep enough to reach the muscle and could result in improper placement, potentially affecting the medication's effectiveness and increasing the risk of irritation at the injection site.
C) 15 degrees: A 15-degree angle is far too shallow for an intramuscular injection and is typically used for intradermal injections, where the medication is injected just beneath the skin into the dermal layer. Using such a shallow angle for an IM injection would likely cause the needle to remain in the subcutaneous tissue, preventing the medication from reaching the muscle layer and significantly reducing its effectiveness.
D) 60 degrees: A 60-degree angle is too steep for intramuscular injections. At this angle, the needle may not effectively reach the muscle tissue and could cause the medication to be injected too superficially into the subcutaneous layer. This would not allow for proper absorption of the drug and may lead to irritation or a delayed therapeutic effect.
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