A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first?
Measure the client's vital signs.
Complete an incident report.
Inform the nurse manager.
Call the provider.
The Correct Answer is A
Choice A reason: Measuring the client's vital signs is the first action that the nurse should perform, as it helps to assess the client's condition and the possible effects of the medication error. The nurse should monitor the client's blood pressure, heart rate, and respiratory rate closely and report any changes or abnormalities to the provider.
Choice B reason: Completing an incident report is not the first action that the nurse should perform, as it does not address the client's immediate needs or safety. The nurse should complete an incident report after providing care to the client and documenting the medication error in the client's record. The incident report should include the facts of the error, the actions taken, and the outcome of the client.
Choice C reason: Informing the nurse manager is not the first action that the nurse should perform, as it does not provide any intervention or treatment for the client. The nurse should inform the nurse manager after measuring the client's vital signs and calling the provider. The nurse manager can offer support and guidance to the nurse and help with the follow-up actions.
Choice D reason: Calling the provider is not the first action that the nurse should perform, as it does not give the nurse any information about the client's status or the severity of the error. The nurse should call the provider after measuring the client's vital signs and reporting the findings. The provider can order any necessary tests or treatments for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.
B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.
C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.
D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.
Correct Answer is C
Explanation
Choice A reason: This response is inappropriate because it violates the client's right to privacy and confidentiality. The nurse should not disclose any information about the client to anyone without the client's consent, unless it is required by law or for the client's safety.
Choice B reason: This response is inappropriate because it shows a lack of accountability and professionalism. The nurse should not dismiss the visitor's concern or pass the responsibility to another nurse. The nurse should either provide the information if they have it or direct the visitor to the appropriate source.
Choice C reason: This response is appropriate because it respects the client's privacy and confidentiality, while also addressing the visitor's concern. The nurse should inform the visitor that they will contact the nurse who is taking care of the client and ask them to come and talk with the visitor.
Choice D reason: This response is inappropriate because it violates the client's privacy and confidentiality. The nurse should not access the client's medical record without a valid reason or the client's consent. The nurse should only check the medical record if they are involved in the client's care or have a need to know the information.
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