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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Warm extremities are not typically associated with peripheral arterial disease (PAD). PAD usually results in reduced blood flow, leading to cooler extremities.
Choice B rationale
Darkened skin color near extremities is more commonly associated with venous insufficiency rather than PAD. PAD typically causes pale or bluish skin due to reduced blood flow.
Choice C rationale
Intermittent claudication, which is pain or cramping in the legs during exercise that subsides with rest, is a hallmark symptom of PAD. It occurs due to reduced blood flow to the muscles during activity.
Choice D rationale
Edema is more commonly associated with venous insufficiency or heart failure rather than PAD. PAD typically causes reduced blood flow, not fluid accumulation.
Correct Answer is C
Explanation
Choice A rationale
A red and beefy tongue is not a symptom of digoxin toxicity. This symptom is more commonly associated with vitamin B12 deficiency or other nutritional deficiencies.
Choice B rationale
Constipation is not a typical symptom of digoxin toxicity. Digoxin toxicity primarily affects the gastrointestinal system with symptoms such as nausea, vomiting, and diarrhea, rather than causing constipation.
Choice C rationale
Yellow vision, or xanthopsia, is a classic symptom of digoxin toxicity. Digoxin can cause visual disturbances, including seeing halos around lights and a yellow tint to vision, due to its effects on the optic nerve.
Choice D rationale
Gaining weight is not a symptom of digoxin toxicity. Weight gain is more commonly associated with fluid retention in conditions such as heart failure, which digoxin is used to treat.
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