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
Constipation is not a common adverse effect of aspirin therapy. Aspirin primarily affects the gastrointestinal tract by causing irritation, which can lead to symptoms such as nausea, vomiting, and abdominal pain. Constipation is more commonly associated with medications that slow down bowel movements, such as opioids.
Choice B rationale
Blurred vision is not typically associated with aspirin therapy. Aspirin is a nonsteroidal anti- inflammatory drug (NSAID) that works by inhibiting the production of prostaglandins, which are involved in inflammation and pain. Blurred vision is more commonly associated with medications that affect the central nervous system or have anticholinergic effects.
Choice C rationale
Insomnia is not a common adverse effect of aspirin therapy. Aspirin does not have stimulant properties that would interfere with sleep. Insomnia is more commonly associated with medications that have stimulating effects, such as caffeine or certain antidepressants.
Choice D rationale
Bleeding is a well-known adverse effect of aspirin therapy. Aspirin inhibits platelet aggregation, which can increase the risk of bleeding. This can manifest as gastrointestinal bleeding, easy bruising, or prolonged bleeding from cuts. Patients taking aspirin should be monitored for signs of bleeding and advised to report any unusual bleeding to their healthcare provider.
Correct Answer is D
Explanation
Choice A rationale
A high protein diet is not recommended for clients with biliary colic from chronic cholecystitis as it can increase bile production and exacerbate symptoms.
Choice B rationale
A high fiber diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice C rationale
A low sodium diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice D rationale
A low fat diet is recommended for clients with biliary colic from chronic cholecystitis as it reduces the workload on the gallbladder and decreases the risk of gallstone formation.
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