A nurse is caring for a client who was administered more than the prescribed dose of a medication. Which of the following actions should the nurse take first?
Notify the primary care provider.
Obtain the client's vital signs.
Educate the client about potential adverse effects.
Complete an incident report.
The Correct Answer is B
A. Notify the primary care provider: Notifying the provider is important, but first, the nurse should assess the client’s condition by obtaining vital signs. This helps determine if immediate intervention is needed, like administering antidotes or treatments.
B. Obtain the client's vital signs: The first step is assessing the client’s physical status by checking vital signs. This helps identify signs of toxicity or immediate adverse effects from the overdose, guiding further actions.
C. Educate the client about potential adverse effects: Education is important, but it’s not the first priority in the case of an overdose. The nurse should first focus on assessing and stabilizing the client before providing information on potential adverse effects.
D. Complete an incident report: While an incident report is necessary, it is not the immediate priority. The nurse must first ensure the client’s safety and health by assessing and managing the overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Advance the needle 6 mm (7 in) below the skin's surface: Intradermal injections should be administered just beneath the skin, not deeply. The needle should be inserted at an angle to form a small bleb just below the epidermis. This depth ensures proper absorption.
B. Point the bevel of the needle upward prior to insertion: The bevel should be facing upward when performing an intradermal injection to ensure the medication is injected just below the skin surface. This positioning helps form a visible wheal or bleb, which is necessary for the tuberculin test.
C. Administer the injection on the dorsal forearm: The recommended site for an intradermal tuberculin test is the inner aspect of the forearm, not the dorsal forearm. The inner forearm provides a flatter surface for easy visualization of the wheal.
D. Insert the needle at a 20° angle to the client's skin: An intradermal injection should be administered at a 5-15° angle to ensure the needle is positioned just beneath the skin’s surface. A 20° angle may result in the injection being too deep.
Correct Answer is ["A","C","D"]
Explanation
A. "Empty the ostomy pouch when it becomes one-third full of contents.": It is important to empty the ostomy pouch when it is about one-third full to prevent leakage and pressure on the stoma. This helps avoid skin irritation and maintain comfort.
B. "Expect the stoma to turn a purple-blue color as it heals.": A stoma should be a reddish-pink color. A purple or blue color indicates poor circulation and may signal complications such as ischemia, which requires immediate attention.
C. "Cut the opening of the pouch an inch larger than the stoma.": The opening of the ostomy pouch should be cut about one-quarter to one-half inch larger than the stoma to prevent irritation or pressure on the stoma. This ensures a good fit and reduces risk of skin damage.
D. "Place a piece of gauze over the stoma while changing the pouch.": Placing gauze over the stoma during pouch changes protects the skin around the stoma fromcontact with stooland absorbs any drainage.
E. "Use povidone-iodine to clean around the stoma.": Povidone-iodine is too harsh for cleaning the stoma area and may cause skin irritation. The recommended cleaning solution is warm water and mild soap, followed by proper drying, to avoid skin damage and infection.
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