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 C
Explanation
A. The statement "Nonmaleficence is doing what is good for a client" is incorrect. Nonmaleficence is the ethical principle of "do no harm." It means avoiding actions that could harm the patient and ensuring that the benefits of treatment outweigh the potential risks.
B. The statement "Fidelity means not doing anything that can harm the client" is partially correct. Fidelity is the ethical principle of faithfulness and keeping promises. It involves being loyal to patients and maintaining trust. While it is related to avoiding harm, it specifically emphasizes keeping commitments and being trustworthy.
C. The statement "Veracity means telling the truth and being honest" is correct. Veracity is the ethical principle of truth-telling and honesty. It involves providing accurate and complete information to patients, promoting transparency in communication.
D. The statement "Beneficence is being fair and impartial to a client" is incorrect. Beneficence is the ethical principle of doing good for the patient, promoting their well-being, and advocating for their best interests. Fairness and impartiality are more aligned with the principle of justice.
Correct Answer is B
Explanation
A.Opening windows during a fire can increase airflow, which may actually intensify the flames and spread the fire faster. Instead, clients should close doors to contain the fire and smoke, stay low to the ground to avoid inhaling smoke, and focus on evacuating the home safely.
B.Storing the fire extinguisher away from the stove ensures it remains accessible if a fire breaks out on or near the stove. If a fire occurs, the extinguisher should be in a location that is easy to access but away from the immediate fire source to prevent the person from reaching through flames to retrieve it.
C.The correct technique is to aim the nozzle at the base of the flames, where the fuel source is. This helps to smother the fire more effectively, as aiming at the base cuts off the fuel source, whereas aiming at the top would be less effective.
D.The batteries in smoke alarms should generally be changed every 6-12 months to ensure they are functioning properly. Many recommendations also suggest testing alarms monthly and replacing the entire smoke alarm every 10 years.
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