A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
Complete an incident report.
Notify the nurse manager.
Call the client's provider.
Assess the client.
The Correct Answer is D
A. While completing an incident report is important for documentation and quality improvement, it is not the immediate priority in the event of a medication error.
B. Notifying the nurse manager is a necessary step for reporting the error, but it should occur after ensuring the client's safety.
C. Calling the client's provider is essential to discuss the medication error and possible interventions, but the client's health and safety must be assessed first.
D. Assessing the client is the priority action to ensure the client’s safety and to identify any adverse effects resulting from the wrong medication. The nurse needs to determine the client's vital signs, level of consciousness, and any immediate symptoms related to the medication administered.
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Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
Correct Answer is A
Explanation
A. Dehydration is a common finding in clients who have experienced diarrhea for several days, as they may have lost significant fluid and electrolytes.
B. A rigid abdomen is more characteristic of conditions such as perforation or severe peritonitis rather than diarrhea.
C. Decreased bowel sounds may occur in certain conditions, but diarrhea typically presents with increased bowel sounds due to hyperactivity.
D. Hypothermia is not a common finding associated with diarrhea; instead, clients may have a normal or elevated temperature due to potential underlying infections.