A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
Fill out an incident report.
Report the incident to the nurse manager.
Notify the provider.
Measure the client's vital signs.
The Correct Answer is D
A. Fill out an incident report. While completing an incident report is necessary for documentation and quality improvement, it is not the priority action. The nurse must first assess the client's condition to address any immediate risks.
B. Report the incident to the nurse manager. Informing the nurse manager is important for accountability and follow-up, but client safety and assessment come first before escalating the issue to management.
C. Notify the provider. The provider should be informed after the nurse has assessed the client and gathered relevant data such as vital signs. This allows the provider to make informed decisions about further treatment or monitoring.
D. Measure the client's vital signs. Assessing the client is the first priority following a medication error to identify any adverse effects. Vital signs provide immediate data on the client’s physiological status and guide urgent interventions if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Weak femoral pulses. Coarctation of the aorta is a congenital narrowing of the aorta, which leads to reduced blood flow to the lower extremities, resulting in weak or absent femoral pulses—a hallmark finding of this condition.
B. Increased intracranial pressure. This is not directly associated with coarctation of the aorta. While severe hypertension can lead to neurologic symptoms, increased ICP is not a typical or early finding.
C. Upper extremity hypotension. The condition causes hypertension in the upper extremities and hypotension in the lower extremities due to the location of the narrowing. Upper extremity hypotension would be an unexpected finding.
D. Frequent nosebleeds. While nosebleeds may occur in older children or adults with uncontrolled hypertension, they are not an expected finding in infants with coarctation of the aorta.
Correct Answer is D
Explanation
A. "Why are you eating seaweed soup?" This response is judgmental and dismissive of the client’s cultural practices. It can make the client feel misunderstood or disrespected.
B. "The hospital food is more nutritious for you." This statement is inaccurate and culturally insensitive, assuming that hospital food is superior without recognizing the nutritional and emotional value of traditional foods.
C. "Does the doctor know that you are eating that?" This implies unnecessary medical concern and may make the client feel like her personal choices require approval, which can be disempowering and disrespectful.
D. "Of course, I will heat that up for you." This response is supportive and culturally competent, respecting the client's traditions and preferences while promoting comfort and emotional well-being during the postpartum period.
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