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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.

A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.

C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.

D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.

A. Confusion B. Apnea C. Cyanosis D. Dysrhythmias

Correct Answer is A

Explanation

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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The nurse realizes that a medication error may have occurred. The nurse's first responsibility is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

Correct Answer is B

Explanation

The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Correct Answer is A

Explanation

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