When leaving a client's room, the practical nurse (PN) realizes that the wrong medications were given to the client. What action should the PN take?
Observe the client closely for one hour.
Give an antidote to the medication.
Ask if the client can spit out the medication.
Report the error to the pharmacy.
The Correct Answer is A
A. Observe the client closely for one hour: The immediate priority after a wrong medication is to monitor the client for adverse reactions or side effects. Close observation allows the PN to detect early signs of toxicity or complications and respond promptly.
B. Give an antidote to the medication: Administering an antidote is only appropriate if the medication has a known reversal agent and the client demonstrates symptoms. Giving one preemptively without signs can be unsafe.
C. Ask if the client can spit out the medication: Once a medication has been swallowed, it cannot reliably be removed, making this intervention ineffective and unsafe.
D. Report the error to the pharmacy: Reporting is necessary as part of follow-up and documentation, but the first action is to ensure client safety through observation and assessment before initiating reporting procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Massage the uterus to decrease atony: Uterine massage is indicated when the uterus is boggy or soft, suggesting atony. In this case, the uterus is already firm, so massaging it would not address the problem and can cause unnecessary discomfort or trauma to the uterine tissue.
B. Assess the bladder for distension: A firm but displaced uterus (dextroverted and elevated above the umbilicus) typically indicates bladder distension. A full bladder pushes the uterus upward and to the side, interfering with normal uterine involution and increasing the risk of postpartum bleeding.
C. Check the hemoglobin to determine uterine hemorrhage: While assessing hemoglobin levels helps monitor blood loss over time, it is not an immediate action to correct uterine displacement. The priority is to identify and relieve the cause of uterine deviation.
D. Provide a stool softener for constipation: Constipation is common postpartum, but it does not cause uterine displacement or affect lochia flow. Addressing bowel function is important, but it is not the immediate priority when the uterus is high and deviated.
Correct Answer is B
Explanation
A. Episodes of vertigo and loss of balance: These findings are more commonly associated with vestibular or neurological disorders rather than IV fluid complications. They do not directly indicate fluid overload or electrolyte imbalance from normal saline infusion.
B. Fatigue and breathlessness upon exertion: These symptoms suggest fluid volume excess, which can occur when IV fluids accumulate faster than the body can handle. Older adults are especially prone to heart failure and pulmonary congestion, leading to dyspnea and generalized fatigue from decreased oxygen exchange.
C. Apical pulse rate of 64 beats/minute: A pulse rate within this range is normal for many adults and does not indicate fluid imbalance or overload. It reflects a stable cardiovascular status rather than a complication of IV therapy.
D. Average 24-hour urinary output of 1,400 mL: This urinary output is within normal limits for an adult (about 30 mL/hour minimum). It indicates adequate renal function and does not signal fluid overload or retention related to IV therapy.
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