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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Correct Answer is C
Explanation
A. Report the occurrence to the nursing supervisor:
While reporting the occurrence is important, verifying the DNR status takes precedence. The nurse needs to gather information and confirm whether the patient has a current DNR order before escalating the issue to a higher authority.
B. Complete an incident report stating the facts of the situation:
Completing an incident report is a part of the process, but it should not be the first action. The immediate concern is to determine if the patient has a valid DNR order. An incident report can be completed later to document the situation and any actions taken.
C. Verify the DNR prescription is current in the medical record.
Verifying the DNR (do-not-resuscitate) prescription is the first and most immediate action the nurse should take. It is crucial to confirm the current status of the DNR order to ensure that the healthcare team is following the patient's wishes. If the DNR is indeed valid and up-to-date, it means the resuscitation efforts, including CPR, were contrary to the patient's expressed wishes.
D. Request a meeting with the ethics committee:
Contacting the ethics committee may be necessary depending on the circumstances, but it is not the first step. Verifying the DNR status is an immediate action that can guide subsequent decisions. If there are ethical concerns or conflicts, involving the ethics committee can be considered after confirming the facts surrounding the DNR order.
Correct Answer is D
Explanation
"I might have trouble staying on a low-fat diet after my surgery." This statement, while relevant to postoperative care, is not a reason to delay obtaining the signature or notify the provider. The client's ability to adhere to a low-fat diet is a matter for preoperative education and counseling.
"I can resume my normal activities in 1 to 2 weeks." This statement, while reflecting the client's expectations for recovery, is not a reason to delay obtaining the signature or notify the provider. It indicates the client's understanding of the anticipated postoperative timeline.
"I will plan to be in the hospital for 24 hours following my surgery." This statement is incorrect as it relates to the type of surgery being performed (laparoscopic total cholecystectomy). Hospital stays for this procedure are typically shorter, often involving an overnight stay or even less. This discrepancy should be clarified with the provider before obtaining the signature.
"I hope that removing my appendix will make me feel better." This statement is incorrect and indicates a misunderstanding of the procedure. A laparoscopic total cholecystectomy involves the removal of the gallbladder, not the appendix. The nurse should delay obtaining the signature and notify the provider to ensure the client understands the correct procedure and its implications.
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