A nurse realizes that they failed to administer a medication that was due 4 hr ago to a client.
Which of the following actions should the nurse take first?
File an incident report.
Determine factors that led to the omission.
Assess the client for adverse reactions.
Report the missed dosage to the client's provider.
The Correct Answer is C
The first action the nurse should take is to assess the client for adverse reactions.
It is important to ensure the client’s safety and well-being before taking any further actions.
Choice A is wrong because filing an incident report is not the first action the nurse should take.
Choice B is wrong because determining factors that led to the omission is not the first action the nurse should take.
Choice D is wrong because reporting the missed dosage to the client’s provider is not the first action the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
First, convert the client’s weight from pounds to kilograms: 121 lb /.2 = 55 kg. Then, calculate the dose in mg: 1 mg/kg * 55 kg = 55 mg.
Finally, use the ratio of available enoxaparin to calculate the volume to administer: (55 mg / 60 mg) * 0.6 mL = 0.55 mL.
Rounded to the nearest tenth, this is 0.6 mL.
Choice A is wrong because it is less than the calculated dose of 0.6 mL.
Choice B is wrong because it is equal to the calculated dose of 0.6 mL but not rounded to the nearest tenth.
Choice D is wrong because it is greater than the calculated dose of 0.6 mL.
Correct Answer is A
Explanation
The nurse should monitor the client for hearing loss because it is a potential adverse effect of erythromycin.
Choice B is wrong because a high-fiber diet to prevent constipation is not mentioned as a necessary action when administering erythromycin lactobionate IV bolus.
Choice C is wrong because erythromycin lactobionate IV bolus should not be administered over 10 min; bolus injection (IV push) is contraindicated.
Choice D is wrong because erythromycin lactobionate should not be reconstituted with a 5% dextrose solution; it should be reconstituted with sterile water for injection.
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