a nurse is caring for a client and realizes they have administered the wrong medication which of the following actions should the nurse take first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.

2. A healthcare provider is reviewing the medical record of a client who has a new prescription for clozapine. Which of the following findings indicates a contraindication to clozapine?

Correct answer: D

Rationale: A low WBC count (3,300/mm3) is a contraindication to clozapine because this medication can cause severe neutropenia. Neutropenia is a significant reduction in white blood cell count, increasing the risk of infections. Elevated fasting blood glucose, asthma, and hypertension are not direct contraindications to clozapine.

3. A client was exposed to anthrax. Which of the following antibiotics should be administered?

Correct answer: C

Rationale: The correct answer is Ciprofloxacin. Ciprofloxacin is an antibiotic effective in treating anthrax exposure. Fluconazole (Choice A) is an antifungal medication used for fungal infections, not anthrax. Tobramycin (Choice B) is an antibiotic used for bacterial infections but is not the first line of treatment for anthrax. Vancomycin (Choice D) is also an antibiotic, but it is not the preferred choice for treating anthrax.

4. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

5. A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. Clear fluid draining from the ear may indicate a cerebrospinal fluid (CSF) leak, which is a serious complication following a head injury. Reporting this finding is crucial as it may require immediate medical intervention to prevent further complications. Choices A, B, and D are not as concerning as a CSF leak. A GCS score of 12 is relatively high, indicating a mild level of consciousness alteration. An edematous bruise on the forehead is a common physical finding after a head injury. Pupils that are 4 mm and reactive to light suggest normal pupillary function.

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