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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Enrolling the UAP in a hospital education class on conducting safe client care is unnecessary at this moment. The immediate concern is ensuring the client's safety during the procedure.
B. Stopping the procedure and instructing the UAP to place the client in Fowler's position (or at least semi-Fowler's) is the correct action. This position helps prevent aspiration during oral hygiene for an unconscious client.
C. Praising the UAP for performing oral hygiene does not address the safety risk present in this situation. While family participation is encouraged, it should not be the focus here.
D. Telling the UAP to continue because the unconscious client is positioned safely is incorrect, as the flat side-lying position increases the risk of aspiration. Ensuring the client is positioned properly is essential for their safety.
Correct Answer is A
Explanation
A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.
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