A nurse is assessing a client for signs and symptoms of a medication error. Which of the following manifestations should the nurse be most concerned about?

Mild headache and dizziness

Temporary nausea and vomiting

Rapid heart rate and palpitations

Transient muscle weakness and fatigue

Answer and Explanation

The Correct Answer is C

Rapid heart rate and palpitations are potential signs of a medication error, particularly if the client is receiving medication that can affect cardiac function. These symptoms can indicate an adverse reaction or an overdose of certain medications, such as those that affect the cardiovascular system. Monitoring the client's cardiac status is crucial in detecting and managing potential medication errors.

Incorrect choices:

a) Mild headache and dizziness: While these symptoms may be bothersome, they are generally not indicative of a medication error unless they persist or worsen.

b) Temporary nausea and vomiting: Nausea and vomiting can occur as side effects of medications, and they may not necessarily indicate a medication error.

d) Transient muscle weakness and fatigue: Although muscle weakness and fatigue can be associated with medication errors, they are less specific and may be caused by various other factors. Rapid heart rate and palpitations are more concerning in this context.

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Correct Answer is C

Explanation

An allergic reaction to a newly administered medication can be a strong indicator of a medication error. It suggests that the client may have received a medication to which they are allergic or that they were given an incorrect dose or formulation of the medication. Allergic reactions require immediate intervention to prevent further harm.

Incorrect choices:

a) The client reports mild constipation: Mild constipation is a non-specific symptom that may or may not be related to a medication error. It can occur for various reasons, including dietary changes or side effects of the medication.

b) The client's blood pressure remains within normal limits: Blood pressure within normal limits does not necessarily indicate or rule out a medication error. It is important to assess for other specific signs and symptoms related to the medication.

d) The client exhibits improved mood and increased energy: Improved mood and increased energy are positive outcomes that may occur with the appropriate use of medication. They do not suggest a medication error unless accompanied by other concerning signs or symptoms.

A. Stop the infusion and notify the provider. B. Administer diphenhydramine as prescribed. C. Monitor the client's vital signs and oxygen saturation. D. Slow down the infusion rate and observe for improvement.

Correct Answer is A

Explanation

A) This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.

B) This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.

C) This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.

D) This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.

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