After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Document the event in the electronical health record.

Complete an incident report.

Inform the nurse on the next shift.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is B

A.   Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B.   When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C.   While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D.   Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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Correct Answer is A

Explanation

A. After a myocardial infarction, it is important to monitor the client’s blood pressure before they start ambulating to assess their hemodynamic stability. Changes in blood pressure during or after ambulation could indicate problems such as orthostatic hypotension or cardiovascular instability.
B. While monitoring urinary output is important for assessing renal function and fluid balance, it is not the most immediate concern when preparing the client to ambulate post-MI. The priority is to ensure cardiovascular stability and safety during ambulation, so other interventions take precedence in this situation.
C. Dietary teaching about a cardiac diet is important for long-term management and recovery after an MI. However, it is not the immediate concern when the client is preparing to ambulate for the first time. The priority at this moment is to ensure the client’s safety and stability during the initial physical activity.
D. Vital signs should certainly be monitored, but the more immediate concern when the client is preparing to ambulate is ensuring cardiovascular stability and assessing any potential risk factors that could arise during the activity.

A. Ask the client to describe the pain experienced. B. Provide the client with a visual analog scale. C. Instruct the client in use of a numeric pain scale. D. Gently palpate the area and observe the response.

Correct Answer is A

Explanation

A. Asking the client to describe the pain is the most direct way to gather information about the quality of the pain. This approach allows the client to express characteristics such as whether the pain is sharp, dull, burning, aching, throbbing, or stabbing.
B. A visual analog scale (VAS) is useful for assessing the intensity of pain, not the quality. The VAS typically involves a line with endpoints representing no pain and worst possible pain, where the client marks their pain level.
C. The numeric pain scale is designed to measure the intensity of pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable. Like the VAS, this scale assesses pain intensity rather than quality.
D. Palpation and observing the client's response can help assess the location and intensity of pain, particularly if there are physical findings associated with the pain. However, this method does not provide information about the pain’s quality, such as its character or nature.

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After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

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Naxlex Comprehensive Predictor Exams

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