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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.

Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.

A. Has data been collected about specific client needs related to turning? B. Does the AP have time to change the client's central IV line dressing after turning her? C. Has the AP checked the client's pain level prior to turning her? D. Is the client's family present so the AP can show them how to turn the client?

Correct Answer is C

Explanation

Choice A reason: Data collection about specific client needs related to turning is not an assessment that the nurse should make before delegating care, but rather a task that the nurse should perform and communicate to the AP. The nurse should identify the client's risk factors, preferences, and goals for turning and share them with the AP.

Choice B reason: Changing the client's central IV line dressing is not a task that the nurse should delegate to the AP, as it requires sterile technique and infection control. The nurse should perform this task and document the findings and interventions.

Choice C reason: Checking the client's pain level prior to turning her is an assessment that the nurse should make before delegating care, as it affects the client's comfort and safety. The nurse should ensure that the client's pain is adequately managed and that the AP is aware of the client's pain status and medication regimen.

Choice D reason: The presence of the client's family is not an assessment that the nurse should make before delegating care, but rather a factor that the nurse should consider and respect when planning and implementing care. The nurse should involve the client's family in the care process as much as possible and provide them with education and support.

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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?

Nursing Test Bank

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