The nurse realizes that a medication error may have occurred. The nurse's first responsibility is to:
document the error.
call the physician.
notify the supervisor.
assess the client.
The Correct Answer is D
D. Assessing the client is the nurse's first responsibility when a medication error is suspected. The nurse should promptly assess the client's condition to determine if any harm has occurred as a result of the error. This assessment includes vital signs, physical assessment, and evaluation of any signs or symptoms related to the medication error.
A. Documenting the medication error is important for accurate record-keeping and subsequent investigation. However, it should not be the nurse's first action. The priority should be to assess and address any potential harm to the client.
B. Calling the physician may be necessary depending on the severity of the error and the client's condition. However, it is not the first responsibility of the nurse in response to a suspected medication error. The nurse's primary concern should be the immediate assessment and management of the client's condition.
C. Notifying the supervisor or charge nurse is an important step to report the incident and seek guidance on next steps. Supervisors can assist in managing the situation, implementing corrective measures, and ensuring appropriate documentation and reporting procedures are followed. This is typically one of the first actions after ensuring the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.
E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.
B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.
C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.
D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.
Correct Answer is ["B","C","E"]
Explanation
B. According to Medicare and The Joint Commission guidelines, the use of patient restraints requires a physician's order. The order should specify the reason for the restraint, the type of restraint, and the duration or conditions for its use.
C. Before using restraints, healthcare providers must exhaust all alternative, less restrictive measures to manage the patient's behavior or condition. This could include environmental modifications, reassurance techniques, or pharmacological interventions.
E. Restraints should be removed or released every 2 hours for reevaluation and to provide opportunities for range of motion exercises, toileting, hydration, and skin care. Restraints should not be used continuously without periodic assessment and reevaluation.
A. Punitive measures are not appropriate or effective in the use of patient restraints. Restraints should only be used for medical reasons to ensure patient safety, not as a form of punishment.
D. Inadequate staffing is not a criterion specified for using patient restraints. Restraints should not be used as a substitute for sufficient staffing levels to monitor and manage patient care.
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