A nurse identifies that a client has received a double dose of a medication in error. Which of the following actions should the nurse take first?
Complete an incident report about the occurrence.
Check the client's vital signs.
Notify the charge nurse of the error.
Document the facts of the incident in the nurse's notes.
The Correct Answer is B
A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.
B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.
C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.
D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["500ml\/hr"]
Explanation
To calculate the mL/hr for the lactated Ringer's IV infusion over 30 minutes, you can use the following formula:
Rate (mL/hr)=Volume (mL)/Time (hr)
In this case:
Rate=250 mL/ 0.5 hr
Rate=500mL/hr
Therefore, the nurse should set the IV pump to deliver 500 mL/hr for the lactated Ringer's IV infusion over 1 hour.
Correct Answer is C
Explanation
Hot tea:
Hot tea may not be well-tolerated by individuals experiencing chemotherapy-induced nausea, as hot or strong-smelling foods and beverages can be triggers. It is generally recommended to choose foods at room temperature.
Soft-serve ice cream:
Soft-serve ice cream may be too cold and could exacerbate nausea or discomfort. Cold foods might not be well-tolerated during or after chemotherapy.
Raisin toast:
This is the correct answer. Raisin toast is a good choice as it is a bland and easily digestible carbohydrate. It can be a suitable option for individuals experiencing nausea, providing some calories without strong odors or flavors.
String cheese:
While cheese can be a good source of protein, string cheese might not be the best choice if the individual is experiencing nausea, as the smell or taste of certain cheeses can be strong and trigger nausea.
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