The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:
A.
tell the nurse manager.
B.
notify the physician.
C.
check the client’s blood pressure.
D.
file an incident report.
The Correct answer and Explanation is:
Correct Answer: C. check the client’s blood pressure.
Explanation:
In this scenario, the nurse’s immediate priority is the client’s safety. The first action the nurse should take after realizing she has administered twice the prescribed dose of antihypertensive medication is to assess the client for any adverse effects caused by the medication error. Since antihypertensive drugs lower blood pressure, administering too much can lead to hypotension, which can be life-threatening. Therefore, the nurse should promptly check the client’s blood pressure to determine if it has dropped to a dangerously low level.
By checking the client’s blood pressure, the nurse can assess the immediate physiological impact of the error and take appropriate steps to manage any complications. If the client’s blood pressure is too low, the nurse can initiate interventions such as placing the client in a supine position with their legs elevated, administering fluids, or, in severe cases, preparing for the administration of vasopressors, as per the physician’s orders. Early detection and intervention can prevent further complications and stabilize the client.
After assessing the client, the nurse should then notify the physician (option B) about the medication error, the client’s current condition, and the steps already taken. This allows the physician to provide additional orders, such as monitoring the client more frequently, administering antidotes if available, or making adjustments to other prescribed medications.
Telling the nurse manager (option A) and filing an incident report (option D) are also necessary steps, but they are not the first actions to take. These actions focus on institutional protocols and documentation rather than the immediate health and safety of the client. The primary focus should always be on assessing and managing any harm to the client before moving on to reporting the error through the appropriate channels.
In summary, the correct sequence of actions is to first assess the client’s condition by checking the blood pressure, then notify the physician, and finally, report the incident according to the facility’s protocols. This approach ensures that the client’s safety is prioritized while still adhering to professional and institutional responsibilities.