Question

A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?

A. Check the client's vital signs. Rationale: The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Collecting additional data will provide the nurse with knowledge to make an appropriate decision.
B. Notify the charge nurse. Rationale: Notifying the charge nurse or other appropriate nursing supervisor is an action the nurse should take; however, it is not the priority action.
C. Fill out an occurrence report according to institutional policy. Rationale: Completing an occurrence form is an action the nurse should take in order to provide quality improvement within the facility; however, it is not the priority action.
D. Document an objective description of what has happened in the client's chart. Rationale: The nurse should document an objective description of what has happened in the client's chart; however, it is not the priority action.

Answer 1

The initial priority for the nurse is to check the client's vital signs after administering nifedipine to the wrong client, following nursing assessment protocols to ensure the client's safety before taking further administrative steps.

Step-by-step explanation:

The priority nursing action when a nurse realizes that nifedipine was administered to the wrong client is to check the client's vital signs. This initial step follows the nursing process priority-setting framework starting with assessment, before any plans or interventions are implemented. Checking vital signs is critical as nifedipine affects blood pressure and heart rate, and any deviations need to be addressed immediately. After assessing the patient and ensuring stability, subsequent steps would include notifying the charge nurse, filling out an occurrence report following institutional policies, and documenting an objective description of what transpired in the client's chart.