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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Discontinue the client's PCA:

The discontinuation of the patient-controlled analgesia (PCA) may be necessary, but assessing the client's vital signs is a priority to ensure the client's overall stability and response to the surgery.

B. Measure the client's vital signs:

This is the correct answer. Assessing vital signs is a priority postoperatively to monitor the client's physiological status, detect any signs of complications, and guide further interventions.

C. Remove the client's indwelling urinary catheter:

Removing the urinary catheter may be part of the postoperative care plan, but it is not the immediate priority. Vital sign assessment is crucial for overall patient monitoring.

D. Change the client's abdominal dressing:

Changing the abdominal dressing is an important aspect of postoperative care, but assessing vital signs takes precedence to identify any signs of distress or instability.

A. Instruct the client to limit flexion of the hips no further than 100". B. Perform range-of-motion exercises every 2 hr. C. Reposition the client every 2 hr. D. Place an abduction pillow between the legs.

Correct Answer is A

Explanation

A. Limiting hip flexion to 100" is an incorrect and potentially unsafe prescription. Such a restriction would severely limit the client's mobility and could impede the recovery process following a total hip arthroplasty. The nurse should clarify this prescription with the provider to ensure that the client is given appropriate instructions for postoperative care.

B. Performing range-of-motion exercises every 2 hours is a standard and appropriate prescription for a postoperative client after a total hip arthroplasty. These exercises help prevent joint stiffness and promote circulation.

C. Repositioning the client every 2 hours is a standard practice to prevent complications such as pressure ulcers and promote comfort and circulation.

D. Placing an abduction pillow between the legs is a common practice after a total hip arthroplasty. It helps maintain proper hip alignment and prevents dislocation of the prosthetic hip joint during the initial postoperative period.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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