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 A
Explanation
Choice A reason: This is the correct choice because an evidence-based nursing journal is a reliable and credible source of information that is based on research and best practices. A nurse can use an evidence-based nursing journal to find current and accurate data on the prevalence of Tay-Sachs disease, as well as the causes, symptoms, diagnosis, treatment, and prevention of the disease.
Choice B reason: This is not the correct choice because the client's health care provider is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The nurse should respect the client's autonomy and privacy and not contact the client's health care provider without the client's consent. The nurse should also avoid relying on the health care provider's opinion or knowledge, which may not be up to date or consistent with the evidence.
Choice C reason: This is not the correct choice because the facility's case manager is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The case manager's role is to coordinate the client's care and services, not to provide information or education on specific diseases. The case manager may not have the expertise or the access to the relevant information that the nurse needs.
Choice D reason: This is not the correct choice because a collaborative, user-edited website is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. A collaborative, user-edited website, such as Wikipedia, is not a reliable or credible source of information, as anyone can edit or add content without verification or peer review. The information on such a website may be outdated, inaccurate, biased, or incomplete.
Correct Answer is B
Explanation
Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.
Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.
Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.
Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.
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