A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

Stop the infusion and notify the provider.

Administer diphenhydramine as prescribed.

Monitor the client's vital signs and oxygen saturation.

Slow down the infusion rate and observe for improvement.

Answer and Explanation

The Correct Answer is A

A) This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.

B) This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.

C) This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.

D) This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.

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Correct Answer is ["A","B","C"]

Explanation

A) This is correct because using two client identifiers, such as name and date of birth, is a standard safety measure to ensure that the right medication is given to the right client.

B) This is correct because checking the expiration date of the medication before administering it is another safety measure to prevent giving expired or ineffective medications to clients.

C) This is correct because comparing the medication label with the prescription three times (before, during, and after preparing the medication) is a recommended practice to prevent errors such as wrong dose, wrong route, or wrong time.

D) This is incorrect because administering the medication as soon as possible after receiving it from the pharmacy may increase the risk of errors due to haste or distraction. The nurse should follow the prescribed schedule and administer the medication within a reasonable time frame.

E) This is incorrect because documenting the medication administration after completing other tasks may lead to forgetting or omitting important information. The nurse should document the medication administration as soon as possible after giving it to the client.

A. The client reports mild constipation B. The client's blood pressure remains within normal limits C. The client experiences an allergic reaction D. The client exhibits improved mood and increased energy

Correct Answer is C

Explanation

An allergic reaction to a newly administered medication can be a strong indicator of a medication error. It suggests that the client may have received a medication to which they are allergic or that they were given an incorrect dose or formulation of the medication. Allergic reactions require immediate intervention to prevent further harm.

Incorrect choices:

a) The client reports mild constipation: Mild constipation is a non-specific symptom that may or may not be related to a medication error. It can occur for various reasons, including dietary changes or side effects of the medication.

b) The client's blood pressure remains within normal limits: Blood pressure within normal limits does not necessarily indicate or rule out a medication error. It is important to assess for other specific signs and symptoms related to the medication.

d) The client exhibits improved mood and increased energy: Improved mood and increased energy are positive outcomes that may occur with the appropriate use of medication. They do not suggest a medication error unless accompanied by other concerning signs or symptoms.

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A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication administration record of a client who has a history of medication errors. Which of the following actions should the nurse take to prevent medication errors? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is C

Explanation

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A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?