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 B
Explanation
A. Flush the tube with 5 mL of water:
Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.
B. Test the pH of fluid aspirated from the tube (Correct Answer):
Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.
C. Inject air through the tubing and auscultate for gurgling sounds:
Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.
D. Change the bag and tubing system every 12 hr:
Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.
Correct Answer is B
Explanation
A. Agree on a desired outcome:
Before agreeing on a desired outcome, it is important to collect relevant facts and information about the situation. Understanding the specifics of the case is crucial for making informed decisions.
B. Collect the relevant facts:
This is the correct answer. Gathering information and understanding the facts surrounding the situation is the initial step in addressing any ethical dilemma. This includes understanding the nature of the medical treatment, reasons for refusal, and potential consequences for the child.
C. Examine personal values:
While personal values are important to consider, examining personal values typically comes later in the ethical decision-making process. The nurse first needs to understand the facts and the context of the situation.
D. Create a plan of action:
Creating a plan of action should be based on a thorough understanding of the situation, including the relevant facts and considerations. It is a step that follows the collection of information.
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