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: Expecting some swelling in the hands and feet is incorrect. Furosemide is a diuretic used to reduce fluid buildup, so swelling should decrease, not increase.
B: Taking the medication at bedtime is not recommended because furosemide increases urine output, which can disrupt sleep. It is better to take it in the morning.
C: Eating foods that contain plenty of potassium is important because furosemide can cause potassium loss. Consuming potassium-rich foods helps maintain electrolyte balance and prevent hypokalemia.
D: Taking aspirin if headaches develop is not related to the use of furosemide. The nurse should address headache management separately and ensure the client understands the specific instructions for furosemide use.

A. Assess characteristics of her sputum. B. Assess pulse and respirations. C. Instruct to slowly exhale with pursed lips. D. Auscultate lung fields.

Correct Answer is D

Explanation

A: Assessing the characteristics of the sputum is important for understanding the nature of the infection and the effectiveness of the treatment, but it is not the first action to take before the procedure.

B: Assessing pulse and respirations is the first action the nurse should take. This provides baseline data on the client’s respiratory and cardiovascular status, which is crucial for monitoring the client’s response to the procedure and ensuring safety.

C: Instructing the client to slowly exhale with pursed lips is a technique used to improve breathing efficiency and oxygenation, but it is not the first action to take before the procedure.

D: Auscultating lung fields is important for assessing the client’s respiratory status and identifying areas of congestion or decreased breath sounds, but it should follow the initial assessment of pulse and respirations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which nursing action should the nurse complete first?

Correct Answer is D

Explanation

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