Safe Dosage
A nurse is preparing to administer a medication to a newly admitted client. The nurse should identify which of the following actions as a part of the assessment phase of the nursing process? a. Asking the client about a history of medication allergies b. Instructing the client about the medication's adverse effects c. Determining whether the medication should be administered with or without meals d. Monitoring the client's response to the medication
a. Asking the client about a history of medication allergies The nurse should identify that data collection is part of the assessment phase of the nursing process. The nurse should collect data regarding the client's prior adverse reactions to medications, laboratory data, use of other medications, and pertinent vital signs as part of the assessment phase to ensure safe medication administration.
A nurse is administering medications to four clients. The nurse should identify which of the following nursing actions as a part of the evaluation phase of the nursing process? a. Collecting information about a client's pain level following administration of a narcotic b. Taking the blood pressure of a client before administering an antihypertensive medication c. Lowering the level of a client's bed before administering a benzodiazepine medication d. Instructing a client to rinse their mouth following administration of an inhalation corticosteroid
a. Collecting information about a client's pain level following administration of a narcotic The nurse should identify that collecting information from a client regarding a medication's therapeutic response is part of the evaluation phase of the nursing process. The nurse should include in the evaluation phase the client's therapeutic response, adverse effects, and client adherence to the medication therapy.
A nurse working in a medical-surgical unit is preparing to administer medications to a client. The nurse plans to use two forms of identification to verify that she has the right client. Which of the following actions can the nurse take to identify the client? ( Select all that apply.) a. Compare the name on the client's wristband with the name in the medication administration record (MAR). b. Ask the client to state his date of birth. c. Check the room number in the medication administration record (MAR) with the room number of the client. d. Ask the client to state his name. e. Use the bar code scan to identify the client.
a. Compare the name on the client's wristband with the name in the medication administration record (MAR). b. Ask the client to state his date of birth. d. Ask the client to state his name. e. Use the bar code scan to identify the client. a. Verifying the data on the client's wrist band is an acceptable method of identification. b. The client's date of birth is an acceptable identifier d. The client's full name is an acceptable identifier. e. Scanning the client's bar code is an acceptable method of identification.
This prescription requires clarification because it is missing the frequency of medication administration. a. Heparin b. Acetaminophen c. Acetylcysteine d. Hydroxychloroquine
a. Heparin The nurse should have a second nurse check the dosage of high-alert medications, such as heparin, because serious client harm can occur if the dosage is excessive. High-alert medication classes include central nervous system drugs, chemotherapeutic agents, and anticoagulants.
When using the nursing process framework, the first action the nurse should take after discovering a medication error is to assess the client's status. This ensures that any adverse effects of the medication error are identified and that relevant interventions are implemented. a. Obtain the client's vital signs. b. Notify the provider. c. Document the client's response in the medical record. d. Tell the client to change positions slowly.
a. Obtain the client's vital signs. The first action the nurse should take when using the nursing process is to assess the client; therefore, the first action the nurse should take is to obtain the client's vital signs.
A nurse is preparing to administer an oral medication. Which of the following actions should the nurse take? (Select all that apply.) a. Provide client education about the medication. b. Check the expiration date of the medication. c. Verify the dosage of the medication. d. Call the client by name to confirm their identity. e. Ask the client if they have any allergies.
a. Provide client education about the medication. b. Check the expiration date of the medication. c. Verify the dosage of the medication. e. Ask the client if they have any allergies. a. The nurse should provide education for the client regarding the name and purpose of each medication when administering them to the client. b. The nurse should review the package information prior to administering the medication, including the expiration date. c. he nurse should review the package information prior to administering the medication, including the medication name and dosage. e. The nurse should ask the client about any allergies that they have to decrease the risk of an adverse reaction.
A nurse is assessing a client following administration of an antibiotic. The nurse should identify that which of the following findings is a manifestation of an anaphylactic reaction to the medication? a. Swollen lips b. Hypertension c. Low heart rate d. Constipation
a. Swollen lips The nurse should identify that swollen lips is a manifestation of an anaphylactic reaction. Other manifestations include stridor, dyspnea, wheezing, urticaria, and pruritis. The nurse should notify the rapid response team, elevate the client's head off the bed, apply high-flow oxygen, and prepare to administer epinephrine.
The first action the nurse should take when using the nursing process is to assess the client; therefore, the first action the nurse should take is to obtain the client's vital signs. a. Validate that the dosage is within the safe range. b. Confirm the medication amount is appropriate for the child. c. Verify that the medication is not expired. d. Check the client's heart rate prior to administration. e. Document the administration in the medication administration record.
a. Validate that the dosage is within the safe range. b. Confirm the medication amount is appropriate for the child. a. The nurse should validate that the dosage is within the safe range by using the child's current weight and a medication reference text that indicates appropriate dosage parameters. Closely adhering to the rights of medication administration, which include the right medication, right dose, right time, right route, right client, and right documentation, helps to reduce medication errors. b. The nurse should confirm the medication amount is appropriate when ensuring administration of the right dose to the child. Closely adhering to the rights of medication administration, which include the right medication, right dose, right time, right route, right client, and right documentation, helps to reduce medication errors.
A nurse is transcribing medication prescriptions for a group[ of clients. Which of the following is the appropriate way for the nurse to record medications that require the use of a decimal point? a. .4 mL b. 0.6 mL c. 8.0 mL d. 125.0 mL
b. 0.6 mL The nurse should place a leading zero to the left of the decimal point when the dose is less than 1 and should not use a trailing zero at the end of the number. This ensures the number is read as "six tenths" of a milliliter.
A nurse is preparing to administer a time-critical medication to a client at 0800. Which of the following times are appropriate for the nurse to administer the medication? ( Select all that apply) a. 0700 b. 0745 c. 0830 d. 8845 e. 0900
b. 0745 c. 0830 d. The nurse should follow facility policy when selecting the time to administer medication to the client. Typically, facility policy permits the nurse to administer a time-critical medication 30 min before or after the scheduled time for administration. 0745 is within 30 min of the 0800 administration time. d. 0830 is within 30 min of the 0800 administration time. Administering time-critical medications, such as antibiotics, in a timely manner helps to maintain therapeutic levels of the medication in the client's blood.
A nurse is preparing to administer insulin subcutaneously to a client. The nurse should document the administration of the medication immediately after which of the following actions? a. Taking the insulin from the automated dispensing machine b. Injecting the insulin c. Checking the client's blood glucose level d. Checking the correct dosage of the insulin
b. Injecting the insulin The nurse should document interventions, such as medication administration, immediately after they occur. The nurse should not delay documentation because this could lead to errors, such as omission of the documentation or administration of a second dose of medication to the client by another nurse. The nurse should never document an action prior to implementation.
Anaphylaxis is a severe allergic reaction that can result in severe bronchoconstriction with laryngeal edema and a precipitous drop in blood pressure. a. Phenytoin 100 mg PO every 8 hr b. Morphine 2.5 mg IV bolus PRN for incisional pain c. Regular insulin 7 units subcutaneous 30 min before breakfast and dinner d. Lisinopril 20 mg PO every 12 hr. Hold for systolic BP less than 110 mm Hg
b. Morphine 2.5 mg IV bolus PRN for incisional pain This prescription requires clarification because it is missing the frequency of medication administration.
A nurse is caring for a client who is to receive topiramate XR 100 mg PO daily. The client tells the nurse that the capsule is too hard to swallow. Which of the following actions should the nurse take? a. Crush the contents of the capsule to administer in a small amount of pudding. b. Request extended-release sprinkles from the pharmacy. c. Ask the charge nurse to clarify the prescription with the provider. d. Withhold the medication until the time for the next dose.
b. Request extended-release sprinkles from the pharmacy. The nurse can administer topiramate XR in sprinkle form, if available. This is not changing the route of the medication. The sprinkle capsules can be opened and mixed with food for ease of swallowing while still remaining extended release.
A nurse is preparing to administer a high-alert pain medication to a client. Which of the following actions should the nurse perform during the planning stage of medication administration? a. Assess the effectiveness of the pain medication. b. Verify the dosage calculation with another nurse. c. Teach the client about the action of the medication. d. Ask the client to state their name and birthdate.
b. Verify the dosage calculation with another nurse. To ensure client safety and prevent harm, the nurse should always have another nurse verify dosage calculation prior to administering a high-alert medication. This occurs during the planning stage of medication administration.
A nurse is preparing to administer medication to a client who has a prescription for docusate sodium 50 mg capsule PO twice daily. The client refuses to take the medication because of nausea. Which of the following actions should the nurse take? a. Administer a docusate sodium capsule rectally. b. Withhold the medication. c. Administer 100 mg docusate sodium with the next scheduled administration. d. Encourage the client to take the medication as the provider prescribed.
b. Withhold the medication. The nurse should withhold the medication due to the client's nausea and notify the provider. If nausea persists, the nurse should contact the provider to prescribe an antiemetic.
A charge nurse is reviewing the types of prescriptions with a newly licensed nurse. Which of the following prescriptions should the nurse include as an example of a standing prescription? a. Oxycodone 5 mg by mouth every 4 hr as needed for pain b. Furosemide 20 mg IV stat c. Acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4 C (101.2 F) d. Diazepam 10 mg IV 30 min prior to procedure
c. Acetaminophen 650 mg by mouth every 6 hr for temperature greater than 38.4 C (101.2 F) A standing prescription is protocol-based and contains directions for administration based upon specific situations, such as the development of a fever.
The nurse should confirm the medication amount is appropriate when ensuring administration of the right dose to the child. Closely adhering to the rights of medication administration, which include the right medication, right dose, right time, right route, right client, and right documentation, helps to reduce medication errors. a. Contact the provider to request an order for a different pain medication. b. Administer oxycodone immediate-release 5 mg PO at 1600. c. Administer oxycodone immediate-release 5 mg PO now. d. Contact the provider to request an increase in the oxycodone extended-release dose.
c. Administer oxycodone immediate-release 5 mg PO now. It has been 15 hr since the previous dose of oxycodone immediate-release, and the medication is prescribed every 4 hr as needed, so the nurse should prepare to administer a dose now to treat the client's pain.
A nurse manager is reviewing a client's medical record and discovers that the client received a double dose of prescriber medication. Which of the following actions should the nurse manager take first? a. Complete an incident report b. Notify the provider about the medication error c. Assess the client for adverse effects d. Report the error to the risk manager
c. Asses the client for adverse effects When using the nursing process, the first step the nurse should take is to assess the client. By checking the client for adverse effects, the nurse can provide prompt treatment to minimize harm to the client.
A single (one-time) order stipulates to administer the medication one time either at a specific time the provider indicates or as soon as possible. a. Notify the provider b. Complete an incident report c. Assess the client. d. Report the error to the nurse manager.
c. Assess the client. When using the nursing process framework, the first action the nurse should take after discovering a medication error is to assess the client's status. This ensures that any adverse effects of the medication error are identified and that relevant interventions are implemented.
A nurse is providing teaching regarding medication administration to a group of newly licensed nurses. Which of the following is a legal responsibility of a nurse? a. Prescribing the correct dosage b. Modifying the medication regimen c. Reporting medication errors d. Delegating administration to assistive personnel
c. Reporting medication errors A nurse is legally responsible for reporting medication errors according to facility policy.
A charge nurse is teaching a newly licensed nurse about medication reconciliation. Which of the following information should the charge nurse include in the teaching? a. Perform medication reconciliation daily during client's hospitalization b. Only newly prescribed medications need to be reviewed during a medication reconciliation c. Vitamins, supplements, and over-the-counter (OTC) medications should be included in medication reconciliation d. The goal of medication is to minimize the financial impact of prescription medications to the client
c. Vitamins, supplements, and over-the-counter (OTC) medications should be included in medication reconciliation The nurse needs to include a list of all medications that the client takes, both prescribed and OTC. Medication reconciliation can identify potential interactions between medications and help avoid possible adverse effects.
The nurse should document interventions, such as medication administration, immediately after they occur. The nurse should not delay documentation because this could lead to errors, such as omission of the documentation or administration of a second dose of medication to the client by another nurse. The nurse should never document an action prior to implementation. a. "Anaphylaxis is a predictable and often unavoidable secondary effect that can occur at a usual therapeutic dose." b. "Anaphylaxis will cause you to experience withdrawal symptoms when you discontinue taking the medication." c. "Anaphylaxis is an unusual response that can occur due to an inherited predisposition." d. "Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening."
d. "Anaphylaxis is a severe hypersensitivity or allergic reaction that is life-threatening." Anaphylaxis is a severe allergic reaction that can result in severe bronchoconstriction with laryngeal edema and a precipitous drop in blood pressure.
A nurse is reviewing a client's prescriptions. The nurse should contact the provider to clarify which of the following prescriptions. a. Ampicillin 100 mg/kg/day by mouth in 4 equally divided doses b. Phenytoin 300 mg by mouth every 12 hours c. Metronidazole 500 mg IV bolus every 6 hr d. Acetaminophen 325 mg every 6 hr PRN for headache
d. Acetaminophen 325 mg every 6 hr PRN for headache This prescription contains name of medication, dosage, frequency, and circumstance for administration, but not the route.
The nurse should have a second nurse check the dosage of high-alert medications, such as heparin, because serious client harm can occur if the dosage is excessive. High-alert medication classes include central nervous system drugs, chemotherapeutic agents, and anticoagulants. a. Routine order b. Stat order c. PRN order d. Single order
d. Single order A single (one-time) order stipulates to administer the medication one time either at a specific time the provider indicates or as soon as possible.
A nurse is teaching a newly licensed nurse about crushing medications. The nurse should explain that which of the following medications can be crushed? a. Extended-release oxycodone b. Sublingual nitroglycerine c. Enteric-coated aspirin d. Sucralfate tablets
d. Sucralfate tablets Sucralfate tablets The nurse should explain that certain medications, such as those that are scored, can be safely crushed and mixed with food or water for a client who has difficulty swallowing. The nurse should check with the pharmacist before crushing a medication to make certain it can safely be crushed.
