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 A
Explanation
The correct answer is choice A. Increased pulse rate.
An aPTT of 90 seconds is much higher than the normal range of 30-40 seconds, which means the blood takes longer to clot and the client is at risk of bleeding. An increased pulse rate is a sign of blood loss and shock.
Choice B is wrong because increased blood pressure is not a sign of bleeding, but rather a sign of hypertension or stress.
Choice C is wrong because decreased temperature is not a sign of bleeding, but rather a sign of hypothermia or infection.
Choice D is wrong because decreased respiratory rate is not a sign of bleeding, but rather a sign of respiratory depression or sedation.
Correct Answer is D
Explanation
The nurse should include paresthesias as an adverse effect of ergotamine in the teaching.
Paresthesias refers to a sensation of tingling, tickling, prickling, or burning of a person’s skin with no apparent physical cause.
Choice A is wrong because blurred vision is not a commonly reported adverse effect of ergotamine.
Choice B is wrong because hematuria is not a commonly reported adverse effect of ergotamine.
Choice C is wrong because tinnitus is not a commonly reported adverse effect of ergotamine.
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