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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3"]
Explanation
To calculate the volume (mL) that the nurse should administer, we can follow these steps:
Convert the weight from pounds to kilograms.
- 1 lb = 0.453592 kg
- 165 lb×0.453592 kg/lb≈74.843 kg
Calculate the total dose using the weight and prescribed dose:
- Total Dose (units)=Dose per kg×Weight (kg)
- Total Dose=8 units/kg×74.843 kg≈598.744 units
Determine the volume using the concentration of the available solution:
- Volume (mL)=Total Dose (units)/Concentration (units/mL)
- Volume =598.744 units/200 units/mL ≈ 2.994 mL
Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.
Correct Answer is D
Explanation
A. The client requires additional help to stand:
While needing additional help to stand is relevant information, it may be expected in Parkinson's disease due to issues with mobility and balance. It is not an immediate priority unless it signals a significant change or poses an immediate risk.
B. The client has increased difficulty dressing:
Increased difficulty dressing is a common manifestation of Parkinson's disease and is important to address but may not be as urgent as issues related to swallowing.
C. The client reports insomnia:
Insomnia is a common issue in Parkinson's disease but may not be an immediate priority unless it significantly impacts the client's overall well-being or contributes to other health concerns.
D. The client has difficulty swallowing:
This is the correct answer. Difficulty swallowing (dysphagia) in Parkinson's disease is a serious concern as it can lead to complications such as aspiration pneumonia and malnutrition. It requires prompt attention and intervention to ensure the client's safety and prevent potential complications.
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