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
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 high-purine diet can lead to the formation of uric acid stones, which are a type of kidney stone. However, it is not the most common risk factor for urolithiasis. Urolithiasis is more commonly associated with factors such as dehydration, which leads to concentrated urine and promotes stone formation.
Choice B rationale
Female gender is not a significant risk factor for urolithiasis. In fact, men are more likely to develop kidney stones than women. The higher incidence in men is thought to be related to differences in diet, fluid intake, and urinary tract anatomy.
Choice C rationale
Dehydration is a major risk factor for urolithiasis. When the body is dehydrated, urine becomes more concentrated, which increases the likelihood of stone formation. Adequate hydration helps to dilute the urine and reduce the risk of stone formation.
Choice D rationale
Family history is a known risk factor for urolithiasis. Individuals with a family history of kidney stones are more likely to develop them due to genetic predispositions that affect factors such as urine composition and kidney function.
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