A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
Report the incident to the nurse manager.
Measure the client's vital signs.
Fill out an incident report.
Notify the provider.
The Correct Answer is B
A. Report the incident to the nurse manager: Reporting to the nurse manager is important for institutional accountability and guidance, but it is not the immediate priority. The client’s safety must be addressed first.
B. Measure the client's vital signs: Assessing the client’s current condition, including vital signs, is the first action because it identifies any immediate physiologic effects of the medication error. This assessment guides subsequent interventions and determines the urgency of notifying the provider.
C. Fill out an incident report: Completing an incident report is required for documentation and quality improvement, but it is secondary to ensuring the client’s safety and assessing for adverse effects.
D. Notify the provider: The provider must be informed to determine medical interventions, but this step follows the initial assessment of the client to establish their current status and identify any immediate threats to safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the client in seclusion when they exhibit signs of anxiety: Seclusion is only indicated for clients who pose a risk of harm to themselves or others, not solely for anxiety. Using seclusion inappropriately can increase agitation and escalate manic behavior.
B. Withdraw the client's TV privileges if they do not attend group therapy: Withholding privileges as punishment is nontherapeutic and can damage rapport. Clients experiencing mania may have impaired attention and judgment, so punitive measures are ineffective and may exacerbate symptoms.
C. Encourage the client to take frequent rest periods: Clients in the manic phase often have decreased need for sleep and may become physically and mentally exhausted. Encouraging rest periods helps prevent fatigue, maintains physiological functioning, and supports overall stabilization during mania.
D. Encourage the client to spend time in the dayroom: While socialization can be therapeutic for some clients, highly stimulating environments may worsen agitation and distractibility in clients experiencing mania. Controlled, low-stimulation settings are often more appropriate.
Correct Answer is C
Explanation
A. Warm the formula in the microwave: Microwaving formula can create hot spots that may cause burns to the child’s gastrointestinal mucosa. The formula should be warmed using a water bath or allowed to reach room temperature for safe administration.
B. Position the child at a 10° to 20° angle after feeding: The child should be positioned at a 30° to 45° angle, at minimum, during and after feeding to reduce the risk of aspiration. A 10° to 20° incline is insufficient for maintaining safe gastric emptying and airway protection.
C. Measure the tubing from the nose to the distal port: Proper measurement from the nose to the distal port (usually ending at the stomach or duodenum) ensures correct placement of the NG tube. Accurate measurement is critical to prevent feeding into the lungs or incorrect placement that could cause complications.
D. Complete the feeding in 5 min: Rapid bolus feeding can cause abdominal distension, vomiting, or aspiration in children. NG tube feedings should be administered slowly over the recommended time frame to promote tolerance and prevent complications.
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