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

Notify the healthcare provider (HCP).

Document the event in the electronic health record (EHR).

Inform the nurse on the next shift.

Complete an incident report.

Answer and Explanation

The Correct Answer is A

Choice A reason: Notifying the HCP immediately ensures prompt evaluation of the medication error’s impact and any needed interventions. Administering an unprescribed antibiotic risks adverse reactions or ineffective treatment. Prompt notification supports patient safety, aligns with error management protocols, and allows the HCP to adjust the care plan accordingly.

Choice B reason: Documenting in the EHR is critical but secondary to notifying the HCP. Immediate notification allows the provider to assess and mitigate harm from the unprescribed antibiotic. Documentation follows to record the error and actions taken, but delaying HCP contact risks prolonged exposure to potential adverse effects.

Choice C reason: Informing the next shift’s nurse ensures continuity but is not the priority. Notifying the HCP first addresses the immediate clinical implications of the unprescribed antibiotic. Shift reports are secondary, as the error requires prompt provider intervention to evaluate the client’s condition and prevent harm from the medication mistake.

Choice D reason: Completing an incident report is necessary for quality improvement but not the first step. Notifying the HCP ensures immediate clinical action to address the unprescribed antibiotic’s effects. Incident reports follow to analyze system issues, but patient safety requires provider notification first to manage potential adverse outcomes.

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Correct Answer is A

Explanation

Choice A reason: Assisting the client to a position like high Fowler’s alleviates shortness of breath by optimizing lung expansion and reducing chest pressure. This immediate intervention improves oxygenation and comfort, critical for dyspnea. Positioning is evidence-based for respiratory distress, addressing the client’s acute symptoms before further assessment or interventions.

Choice B reason: Documenting asymmetric thoracic movement is an assessment, not an intervention, and delays relief of dyspnea. While useful for identifying underlying causes, it does not address immediate shortness of breath or chest pressure. Positioning the client for easier breathing is the priority to stabilize respiratory function and improve comfort.

Choice C reason: Providing an incentive spirometer encourages deep breathing but is less urgent than positioning for immediate dyspnea relief. Spirometry is preventive or rehabilitative, not suitable for acute shortness of breath. Positioning optimizes lung expansion instantly, addressing the client’s respiratory distress and chest pressure more effectively in this scenario.

Choice D reason: Encouraging deep breathing may exacerbate dyspnea or fatigue in acute respiratory distress. Positioning the client first reduces work of breathing, making subsequent deep breathing easier. Without optimizing position, deep breathing is less effective and may increase discomfort, making it a secondary intervention for this client’s symptoms.

A. Young adult client with chronic insomnia and atrial fibrillation being treated with warfarin. B. A client with restless leg syndrome and chronic obstructive pulmonary disease (COPD). C. An older adult client with multiple problems, including obesity, diabetes, and hypertension. D. A client who has a bleeding ulcer, high stress job, and takes flurazepam for sleep.

Correct Answer is C

Explanation

Choice A reason: Chronic insomnia and atrial fibrillation are not direct risk factors for sleep apnea. Warfarin treats clotting but does not affect airway obstruction. Sleep apnea is linked to obesity and anatomical factors, making this client less likely to require regular nighttime assessments compared to an obese, hypertensive client.

Choice B reason: Restless leg syndrome and COPD affect sleep and breathing but are not primary sleep apnea risk factors. COPD causes chronic airflow limitation, not intermittent airway collapse like apnea. Obesity is a stronger predictor, making the obese client with comorbidities a higher priority for regular sleep apnea assessments.

Choice C reason: Obesity, diabetes, and hypertension are strongly associated with obstructive sleep apnea, as excess weight narrows airways, causing intermittent collapse during sleep. Older adults are at higher risk due to reduced muscle tone. Regular nighttime assessments for snoring or apneic episodes are critical to detect and manage this condition, per evidence-based guidelines.

Choice D reason: A bleeding ulcer, high stress, and flurazepam use may disrupt sleep but are not specific to sleep apnea. Flurazepam, a sedative, may worsen undiagnosed apnea by relaxing airway muscles. Obesity remains a stronger risk factor, making the obese client with comorbidities the priority for regular apnea assessments.

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After an IV antibiotic is started, the nurse discovers 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

Which action should the nurse implement for a client with shortness of breath, dyspnea on exertion, and chest pressure?

Correct Answer is A

Explanation

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

Correct Answer is C

Explanation

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