A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client.
Which of the following is the priority nursing action?.
Check the client's vital signs
Notify the charge nurse.
Document an objective description of what has happened in the client's chart.
Fill out an occurrence report according to institutional policy.
The Correct Answer is A
Choice A rationale:
The priority nursing action after administering the wrong medication is to assess the client for any adverse effects. This includes checking the client’s vital signs. Therefore, this statement is correct.
Choice B rationale:
Notifying the charge nurse is an important step, but it is not the first action the nurse should take. Therefore, this statement is incorrect.
Choice C rationale:
Documenting an objective description of what has happened in the client’s chart is necessary, but it is not the first action the nurse should take. Therefore, this statement is incorrect.
Choice D rationale:
Filling out an occurrence report according to institutional policy is necessary, but it is not the first action the nurse should take. Therefore, this statement is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The list obtained from the client should include all medications the client is taking, regardless of who prescribed them.
Choice B rationale:
The reconciliation process should be completed at each transition of care, not just at admission.
Choice C rationale:
Providing a comprehensive list of medications at discharge is a key component of medication reconciliation.
Choice D rationale:
Nurses should not write verbal orders for medications. This is the responsibility of the provider.
Correct Answer is B
Explanation
The correct answer is choice B. Peripheral edema of the ankles.
Choice A rationale:
A blood pressure of 148/94 mm Hg is elevated, but it is not an immediate contraindication for administering nifedipine. Nifedipine is often used to treat hypertension.
Choice B rationale:
Peripheral edema is a common side effect of nifedipine and can indicate worsening fluid retention. The nurse should contact the provider to assess the need for adjusting the medication or implementing additional interventions.
Choice C rationale:
A heart rate of 66/min is within the normal range (60-100/min) and does not require immediate action before administering nifedipine.
Choice D rationale:
An increased alkaline phosphatase level can indicate liver or bone disease, but it is not directly related to the administration of nifedipine. However, it should be monitored and discussed with the provider.
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