The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which action should the nurse complete first?

Complete proper documentation of the medication error in the patient’s chart.

Return to the room to check and assess the patient.

Administer the antidote to the patient immediately.

Alert the charge nurse that a medication error has occurred.

Answer and Explanation

The Correct Answer is B

A: Completing proper documentation of the medication error is important but should not be the first action. Immediate assessment of the patient is more critical.

B: Returning to the room to check and assess the patient is the first priority. The nurse needs to determine if the patient has experienced any adverse effects from the medication error and provide appropriate care.

C: Administering the antidote to the patient immediately is only necessary if the medication given has a known antidote and the patient is showing signs of adverse effects. Assessment should come first.

D: Alerting the charge nurse that a medication error has occurred is important for reporting and follow-up but should follow the immediate assessment and care of the patient.

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Correct Answer is C

Explanation

A: Hyperkalemia refers to high potassium levels, which can occur in ESKD but does not directly cause shortness of breath, swelling, or crackles in the lungs.

B: Hyponatremia refers to low sodium levels, which can occur in ESKD but does not directly cause the symptoms described.

C: Hypervolemia, or fluid overload, is the most likely cause of the client’s symptoms. ESKD can lead to fluid retention, causing shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.

D: Hypovolemia refers to low blood volume, which would not cause the symptoms of fluid overload described in the client.

A. Secure the restraints to the lowest bar of the side rail. B. Ensure four fingers fit under the restraints to prevent constriction. C. Secure the restraints using a quick-release tie. D. Anticipate removing the restraints every 4 hours.

Correct Answer is C

Explanation

A: Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to the bed frame, not the side rail, to prevent injury.

B: Ensuring four fingers fit under the restraints is too loose. The correct fit is typically two fingers to ensure the restraint is secure but not too tight.

C: Securing the restraints using a quick-release tie is correct. This allows for quick removal in case of an emergency.

D: Anticipating removing the restraints every 4 hours is incorrect. Restraints should be checked and potentially removed more frequently, typically every 2 hours, to assess skin integrity and circulation.

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The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which action should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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