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 A
Explanation
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
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