After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Document the event in the electronical health record.

Complete an incident report.

Inform the nurse on the next shift.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is B

A.   Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B.   When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C.   While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D.   Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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Correct Answer is A

Explanation

A. Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B. While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C. Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D. While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

A. Document the presence of orthopnea. B. Elevate the head of the bed. C. Obtain a pulse oximeter. D. Assess the client's vital signs.

Correct Answer is B

Explanation

A. Orthopnea is a condition where a person has difficulty breathing when lying flat and may require sitting or standing to breathe more easily. While documenting orthopnea is important for the medical record and understanding the client’s condition, it is not the immediate priority in addressing acute breathing difficulty.
B. Elevating the head of the bed is an immediate and effective action to help alleviate breathing difficulty. This position helps improve respiratory mechanics by allowing the diaphragm to move more freely and reducing pressure on the lungs.
C. Using a pulse oximeter to measure oxygen saturation is important for assessing the client’s oxygen levels and determining the need for supplemental oxygen. However, this action is secondary to immediately addressing the position that is causing difficulty.
D. Assessing vital signs is important for a comprehensive evaluation of the client’s overall condition and to identify any critical changes in health status. However, in the case of immediate breathing difficulty, it is more urgent to take actions that directly address the breathing issue before performing a thorough assessment.

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After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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