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. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.
B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.
C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.
D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.
Correct Answer is A
Explanation
A. Primary provider: The primary provider is responsible for assessing a client’s capacity to make their own medical decisions. They determine whether the client is able to understand the nature of their condition and the treatment options available.
B. Charge nurse: While the charge nurse plays an important role in overseeing nursing care and ensuring proper communication, the decision about whether a client is capable of making their own medical decisions falls to the primary provider, not the charge nurse.
C. Health care surrogate: A health care surrogate is an individual designated to make medical decisions for a client when they are unable to do so themselves. However, the primary provider is responsible for determining if the client has the capacity to make decisions before a surrogate is involved.
D. Social worker: Social workers provide support and assistance with advance directives and decision-making, but the responsibility for evaluating whether the client can make medical decisions lies with the primary provider, not the social worker.
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