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 C
Explanation
A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.
B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.
C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.
D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.
Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.