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 B
Explanation
A. "Remain on bed rest for 24 hours following the procedure." Prolonged bed rest increases the risk of venous thromboembolism (VTE) and pulmonary complications. Early ambulation or movement is encouraged to promote circulation and prevent complications.
B. "Participate in range-of-motion exercises." Range-of-motion (ROM) exercises help stimulate venous return, improve circulation, and prevent blood stasis, which lowers the risk of postoperative blood clots and muscle stiffness.
C. "Place a pillow under your knees while in bed." Placing a pillow under the knees can impair circulation and increase the risk of venous stasis and thrombus formation. It is not recommended for circulation promotion.
D. "Use an incentive spirometer every 4 hours." While this instruction helps prevent respiratory complications, it is not a direct intervention for improving circulatory function. It's primarily used to promote lung expansion postoperatively.
Correct Answer is A
Explanation
A. Screen the child's visitors for active infections. Neutropenia places the child at high risk for infection due to a severely weakened immune system. Screening visitors for signs of illness is essential to minimize exposure to infectious agents.
B. Prepare the child for a platelet transfusion. Platelet transfusions are used to treat thrombocytopenia, not neutropenia. While leukemia may cause both conditions, neutropenia specifically increases infection risk, not bleeding risk.
C. Monitor the child for indications of active bleeding. While bleeding is a concern in leukemia, it is more directly linked to low platelet levels. The priority intervention for neutropenia is infection prevention, not bleeding control.
D. Initiate a low-protein diet for the child. A low-protein diet is not appropriate for a child with leukemia. These children need adequate protein for healing, immune support, and maintaining strength during treatment.
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