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 A
Explanation
Choice A rationale
Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
Choice B rationale
A yellow tint to the skin is not an expected reaction to rifampin. This could indicate jaundice, a sign of liver dysfunction, which requires immediate medical attention.
Choice C rationale
Lifelong treatment with rifampin is not necessary. The typical duration of treatment for active tuberculosis is 6 to 9 months.
Choice D rationale
Rifampin does not cause amenorrhea when taken with oral contraceptives. However, it can reduce the effectiveness of oral contraceptives, so additional contraceptive methods should be used.
Correct Answer is B
Explanation
Choice A rationale
Urine specific gravity of 1.020 is within the normal range (1.005 to 1.030). This indicates that the urine concentration is normal and does not suggest any abnormality that needs to be reported.
Choice B rationale
Microscopic hematuria refers to the presence of red blood cells in the urine, which is not visible to the naked eye. This finding can indicate a urinary tract infection, kidney stones, or other renal pathology and should be reported to the provider for further evaluation.
Choice C rationale
Amber yellow urine color is considered normal and does not indicate any pathology. The color of urine can vary depending on hydration status and does not necessarily indicate a problem.
Choice D rationale
The absence of glucose in the urine is a normal finding. The presence of glucose in the urine would indicate glycosuria, which is often associated with diabetes mellitus.
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