What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication?

Notify the healthcare provider.

Document the events leading to the error in the nurse's notes.

Complete an incident report documenting the facts.

Assess the client for any adverse effects.

Answer and Explanation

The Correct Answer is D

A)   Incorrect- While notifying the healthcare provider is an important step to take after an error, it's not the first action the nurse should take. The immediate concern is the client's safety and well-being, so assessing the client for any adverse effects of the incorrect dose is the priority.
B)   Incorrect- Documentation is important, but it's not the first action to take after administering an incorrect medication dose. The nurse should prioritize assessing the client for any adverse effects and ensuring their immediate safety.
C)   Incorrect- Completing an incident report is an important step to document errors and prevent future occurrences, but it's not the initial action to take. First, the nurse should focus on the client's well-being by assessing for adverse effects.
D)   Correct- Assessing the client for any adverse effects is the immediate priority when an incorrect dose of medication has been administered. The nurse's first concern is the safety and health of the client. Once the client's condition has been assessed and stabilized, further actions can be taken, such as notifying the healthcare provider and completing incident reports.

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Correct Answer is ["2"]

Explanation

Rationale: The nurse should calculate the dose based on the concentration of the medication. Since the suspension contains 500 mg of acetaminophen per 15 mL, a 1,000 mg dose requires 30 mL (2 tablespoons) of the suspension.

A. Administer a prescribed narcotic antagonist to reverse the eﬀects of any analgesic accumulation. B. Notify the healthcare provider and request a prescription for restraints to minimize the client's danger to self. C. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. D. Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.

Correct Answer is C

Explanation

The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.

The other options are not correct because:

A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.

B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.

D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or eﬀective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.

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What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for acetaminophen 1,000 mg by mouth every 8 hours as needed for pain. The bottle is labeled "Acetaminophen for Oral Suspension, USP 500 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["2"]

Explanation

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Correct Answer is C

Explanation

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