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 B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.
Correct Answer is C
Explanation
A. Giving the medication that is expired poses a risk to the client, as the safety and efficacy of the medication cannot be guaranteed past its expiration date.
B. Returning the medication to the pharmacy may not be feasible in this scenario; proper disposal is generally the nurse's responsibility for expired medications.
C. Discarding the medication is the appropriate action to ensure client safety, as expired medications should not be administered.
D. Notifying the provider is unnecessary in this case; the nurse's responsibility is to discard the expired medication and prepare a new dose that is within its expiration date.