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 C
Explanation
A. Boil bottle rings and nipples for 10 min to ensure sanitization. Boiling for 10 minutes is excessive and can damage bottle parts. A boil time of 5 minutes is typically sufficient for sanitizing feeding equipment before first use.
B. Keep the newborn on a strict 3 hr feeding schedule. Newborns should be fed on demand, which may be more or less frequently than every 3 hours. Hunger cues should guide feeding to promote healthy growth and bonding.
C. Use bottles of refrigerated formula within 48 hr. Prepared formula should be refrigerated and used within 48 hours to ensure safety and prevent bacterial growth. This is a safe practice when storing formula that has not been fed to the infant.
D. Place the newborn on their abdomen for 30 min following each feeding. Placing a newborn on the abdomen increases the risk of sudden infant death syndrome (SIDS). Infants should always be placed on their backs to sleep.
Correct Answer is C
Explanation
A. 1+ pedal edema. Mild pedal edema is typically not associated with instability or falls, unless it progresses to severe swelling that affects mobility or balance. It is a sign of fluid retention but not a direct fall risk indicator on its own.
B. Bruises on the lower extremities. Bruising can be a sign of previous falls or trauma, but it is not itself a cause or indicator of fall risk. While it may prompt further investigation, it does not confirm fall risk independently.
C. Impaired vision. Visual impairment is a significant risk factor for falls because it affects depth perception, ability to detect hazards, and overall spatial awareness. Clients with impaired vision are more likely to trip, misjudge steps, or bump into obstacles.
D. Coarse rhonchi auscultated over the trachea. Coarse rhonchi are respiratory findings typically related to mucus in the airways and do not directly contribute to fall risk unless accompanied by severe respiratory distress or fatigue.
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