A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
Notify the charge nurse.
Check the client’s vital signs.
Fill out an occurrence report according to institutional policy.
Document an objective description of what has happened in the client’s chart.
The Correct Answer is B
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Kernig’s sign is associated with meningitis, not hypocalcemia. It involves pain and resistance when attempting to extend the leg at the knee while the hip is flexed.
Choice B rationale
Brudzinski’s sign is also associated with meningitis, not hypocalcemia. It involves involuntary lifting of the legs when lifting a patient’s head.
Choice C rationale
Chvostek’s sign is a clinical sign of hypocalcemia. It involves twitching of the facial muscles in response to tapping over the facial nerve.
Choice D rationale
Cullen’s sign is associated with acute pancreatitis and involves bruising around the umbilicus. It is not related to hypocalcemia.
Correct Answer is A
Explanation
Choice A rationale
Drinking 16 oz of cranberry juice each day is correct. Cranberry juice has been shown to help prevent UTIs by inhibiting the adhesion of bacteria to the urinary tract lining. This can reduce the risk of infection, especially in individuals prone to recurrent UTIs.
Choice B rationale
Using an over-the-counter douche product after intercourse is incorrect. Douching can disrupt the natural balance of bacteria in the vagina, increasing the risk of infection. It is generally not recommended as a preventive measure for UTIs.
Choice C rationale
Waiting to void until the bladder feels full is incorrect. Delaying urination can lead to the accumulation of bacteria in the bladder, increasing the risk of infection. It is important to urinate regularly and not hold urine for extended periods.
Choice D rationale
Wearing underwear made from nylon is incorrect. Nylon underwear can trap moisture and create a warm, humid environment that promotes bacterial growth. It is better to wear breathable, cotton underwear to reduce the risk of UTIs.
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