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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering the medication with each meal is incorrect. Clopidogrel can be taken with or without food, and there is no specific requirement to administer it with each meal. The primary concern with clopidogrel is monitoring for signs of bleeding.
Choice B rationale
Initiating contact precautions is incorrect. Clopidogrel is an antiplatelet medication and does not require contact precautions. Contact precautions are typically used for infections that can be transmitted through direct or indirect contact.
Choice C rationale
Having suction equipment at the bedside is incorrect. Suction equipment is not necessary for clients taking clopidogrel. The primary concern with clopidogrel is monitoring for signs of bleeding, not respiratory issues.
Choice D rationale
Monitoring the client for black, tarry stools is correct. Clopidogrel increases the risk of bleeding, and black, tarry stools can be an indication of gastrointestinal bleeding. It is important to monitor for this adverse effect to ensure the client’s safety.
Correct Answer is B
Explanation
Choice A rationale
Zucchini is not a significant source of calcium and would not be recommended for increasing calcium intake to reduce the risk of osteoporosis.
Choice B rationale
Collards are a good source of calcium and are recommended for clients at risk for osteoporosis. They provide a substantial amount of calcium, which is essential for bone health.
Choice C rationale
Potatoes are not a significant source of calcium and would not be recommended for increasing calcium intake.
Choice D rationale
Carrots are not a significant source of calcium and would not be recommended for increasing calcium intake.
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