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
Choice A rationale: Administering filgrastim after chemotherapy is a standard practice to boost white blood cell count. However, filgrastim should not be given within 24 hours before or after chemotherapy, as it can affect the efficacy and increase the risk of side effects. Administering the medication 12 hours after chemotherapy falls within this contraindicated window, necessitating an incident report.
Choice B rationale: Filgrastim can be stored at room temperature for short periods, and 2 hours is generally within acceptable limits for stability.
Choice C rationale: An absolute neutrophil count of 2,500/mm³ is within the normal range, and there is no contraindication for administering filgrastim.
Choice D rationale: Flushing the client's IV line with dextrose 5% in water before and after administering filgrastim is not appropriate, as this medication is typically administered with saline solution. Using an incorrect flushing solution could affect the medication's efficacy or compatibility, necessitating an incident report.
Correct Answer is B
Explanation
Ranitidine is a histamine H2-receptor antagonist that blocks histamine-mediated gastric acid secretion.
Antacids can interfere with the absorption of ranitidine, so it is important to separate their administration by at least 1 hour.
Choice A is wrong because aspirin is a type of nonsteroidal anti-inflammatory drug (NSAID) which can increase the risk of peptic ulcers.
Choice C is wrong because fine hand tremors are not a known side effect of ranitidine.
Choice D is wrong because there is no need to avoid dairy products when taking ranitidine.
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