A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?
Fill out an occurrence form.
Administer the medication to the correct client.
Notify the client's provider.
Check the client's vital signs.
The Correct Answer is D
A. Filling out an occurrence form is necessary for documentation and accountability but is not the immediate priority after a medication error.
B. Administering the medication to the correct client should be done, but first, the nurse must ensure the safety and well-being of the client who received the wrong medication.
C. Notifying the client's provider is essential, but the nurse should first assess the client's condition to determine if any immediate actions are necessary.
D. Checking the client's vital signs is the first action the nurse should take to assess the client's current condition and any potential adverse effects from receiving the incorrect medication.
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Correct Answer is D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.
Correct Answer is B
Explanation
A. Urinary retention typically presents with difficulty urinating, rather than changes in urine color or odor.
B. Dark amber, cloudy urine with an unpleasant odor is indicative of a urinary tract infection (UTI). The cloudiness suggests the presence of bacteria or pus, while the dark color and odor are common signs of infection.
C. Urinary incontinence is characterized by the involuntary loss of urine, not changes in the characteristics of urine.
D. Urinary frequency refers to the need to urinate more often, which does not directly relate to the appearance or odor of the urine.