A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first?
Fill out an incident report.
Notify the charge nurse.
Check the client's vital signs.
Document the client's condition in the electronic medical record.
The Correct Answer is C
A. Filling out an incident report is necessary but should not be the first action after administering the wrong medication.
B. Notifying the charge nurse is important, but assessing the client's immediate condition takes priority.
C. Checking the client's vital signs is the first action to assess for any adverse effects from the wrong medication and determine the next steps in care.
D. Documenting the client's condition is important but should occur after assessing the client's vital signs and addressing immediate needs.
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Related Questions
Correct Answer is C
Explanation
Rationales:
A. Pulling the auricle upward and backward is not recommended for administering eardrops to a child as it does not facilitate proper alignment of the ear canal.
B. Pulling the auricle upward and outward is appropriate when administering eardrops to clients >3years old helps straighten the ear canal, allowing for proper administration of the medication into the ear canal for effective treatment.
C. According to the American Academy of Pediatrics, for children under the age of 3, the correct method is to gently pull the outer flap of the affected ear downward and backward. This maneuver helps to straighten the ear canal, allowing the eardrops to flow down into the canal properly.
D. Pulling the auricle down and outward is not recommended for administering eardrops to a child as it does not facilitate proper alignment of the ear canal.
Correct Answer is C
Explanation
A. Asking the client to remain in a side-lying position comes after administering the drops to facilitate medication retention, but it's not the first action.
B. Pulling the client's pinna down and back straightens the ear canal, but this technique is used for children < 3years. For adults the pinna should be pulled upwards and outwards.
C. Warming the medication may not be necessary to prevent dizziness.
D. Placing a cotton ball in the ear canal after instillation is not necessary for otic medication administration and should not be done routinely.
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