a nurse realizes that the wrong medication has been administered to a client which of the following actions should the nurse take first
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam

1. A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?

Correct answer: C

Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.

2. The client is receiving discharge teaching for a new prescription of phenelzine. The nurse should instruct the client that it is not safe to eat which of the following foods while taking this medication?

Correct answer: B

Rationale: Avocados contain high levels of tyramine, which can cause a hypertensive crisis when consumed with phenelzine, a monoamine oxidase inhibitor (MAOI). It is essential for clients taking MAOIs to avoid foods rich in tyramine to prevent dangerous interactions and potential health risks.

3. A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:

Correct answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

4. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

5. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

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