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 A
Explanation
A. Complete an incident report.
Reporting a needlestick injury through an incident report is crucial. It documents the details of the incident, which is important for the nurse's safety and for initiating appropriate follow-up actions.
B. Receive a hepatitis C immunization:
There is no specific hepatitis C vaccine available. While there are vaccines for hepatitis A and hepatitis B, there is currently no vaccine to prevent hepatitis C. Seeking post-exposure prophylaxis and follow-up is more relevant in this case.
C. Notify the health department:
Notifying the health department might be necessary in some cases, but the immediate action for the nurse is to report the incident through an incident report within the facility. This allows for prompt internal investigation and necessary measures.
D. Start prophylactic antibiotic therapy:
Prophylactic antibiotic therapy is not the standard protocol for preventing hepatitis C transmission after a needlestick injury. Antiviral medications might be considered in certain cases for post-exposure prophylaxis for hepatitis C, but this decision should be made after consulting with a healthcare provider or infectious disease specialist based on the specific circumstances of the exposure. Reporting the incident remains the immediate priority.
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