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. The nurse can provide information about the procedure and assist the client in understanding the consent form, but they are not responsible for obtaining informed consent.
B. The surgical suite nurse assists in the surgical environment but does not have the authority to obtain consent.
C. The anesthesiologist discusses the anesthesia involved but does not obtain consent for the surgery itself.
D. The surgeon is responsible for obtaining informed consent, as they must explain the procedure, risks, and benefits to the client before the client can make an informed decision.
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.