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 A
Explanation
A. Perform CPR on the client:
CPR (Cardiopulmonary Resuscitation) is a critical and time-sensitive intervention during a cardiac arrest. An assistive personnel trained in CPR can initiate chest compressions while awaiting further medical assistance.
B. Assist with airway intubation:
Airway intubation is a more advanced skill typically performed by healthcare providers such as physicians or advanced practice nurses. It is beyond the scope of practice for most assistive personnel.
C. Maintain IV access:
Maintaining IV access may require specific skills and knowledge about medications and fluids. While some assistive personnel may be trained in certain aspects of IV care, the level of expertise needed during a cardiac arrest may be beyond their scope.
D. Place defibrillator pads on the client:
Applying defibrillator pads involves handling medical equipment and making critical decisions about when to deliver a shock. This task is typically performed by healthcare providers trained in advanced cardiac life support (ACLS).
Correct Answer is B
Explanation
A. Inserting a straight urinary catheter for a client:
Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.
B. Performing perineal care for a client who has an indwelling urinary catheter.
Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.
C. Showing a client how to use an incentive spirometer:
Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.
D. Increasing oxygen flow for a client who has a nasal cannula:
Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.
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