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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Use perfumes and air fresheners: Using perfumes and air fresheners may actually worsen nausea for some clients, as strong scents can trigger or exacerbate feelings of nausea, particularly in individuals undergoing chemotherapy. It is generally advisable to avoid strong odors in the environment to prevent triggering nausea.
B) Eat foods that are high in fibre: While a balanced diet is important, high-fibre foods may not be helpful in managing nausea and vomiting associated with chemotherapy. In fact, high-fibre foods can sometimes contribute to gastrointestinal discomfort, bloating, or constipation, which may worsen nausea in certain individuals. Therefore, fibre-rich foods are not the best option for reducing nausea and vomiting in this scenario.
C) Drink clear and carbonated beverages: Drinking clear liquids, such as water, ginger ale, or clear broths, can help reduce nausea by keeping the client hydrated and soothing the stomach. Carbonated beverages, such as ginger ale, are often recommended because the bubbles can help alleviate nausea and provide some relief. This is a well-established strategy for managing chemotherapy-related nausea and vomiting.
D) Walk frequently throughout the day: While physical activity is generally beneficial for overall health, walking frequently may not directly address nausea and vomiting caused by chemotherapy. In some cases, walking might even worsen nausea if the client is feeling weak or dizzy. Resting and staying hydrated may be more beneficial in the management of nausea associated with chemotherapy.
Correct Answer is D
Explanation
A. Sodium: Sodium levels are important to monitor, but in the context of pantoprazole use, abnormal sodium levels are less commonly a direct concern. Pantoprazole primarily impacts the gastric environment rather than fluid or electrolyte balance in a way that would dramatically alter sodium levels.
B. Gastric pH: Pantoprazole works to increase gastric pH by reducing acid secretion, which is its primary therapeutic effect. A higher gastric pH is expected and beneficial in conditions like GERD or peptic ulcers.
C. Calcium: Pantoprazole, when used for extended periods, can interfere with calcium absorption, potentially leading to bone health issues like osteoporosis. However, changes in calcium levels typically do not pose an immediate or life-threatening concern unless significantly low or related to prolonged therapy. It is still something to monitor, but magnesium is a higher priority in this case.
D. Magnesium: Pantoprazole and other proton pump inhibitors (PPIs) are known to cause hypomagnesemia, especially with prolonged use. Low magnesium levels can lead to serious complications, including muscle spasms, seizures, and arrhythmias. Hypomagnesemia is a well-documented side effect of long-term PPI use, making it the most critical lab result to address.
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