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 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.
Correct Answer is B
Explanation
Levothyroxine is a thyroid hormone medicine used to treat hypothyroidism (low thyroid hormone)1.
It works by replacing thyroid hormone that is normally produced by the body.
Cold intolerance is a common symptom of hypothyroidism2, so if the client reports that they are not as cold as they used to be, it indicates that the medication is working and their hormone levels are returning to a healthy range.
Choice A is wrong because constipation is a common symptom of hypothyroidism2, so taking a laxative for constipation does not indicate a therapeutic response to the medication.
Choice C is wrong because weight loss without dieting can be a side effect of taking too much levothyroxine.
Choice D is wrong because sleeping more than usual can be a symptom of hypothyroidism2, so it does not indicate a therapeutic response to the medication.
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