A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Documents medication administration prior to administering it.

Verifies the medication against the prescription and medication label.

Checks the provider's orders and confirmed dosage in a medication reference guide.

Scans the bar code on the medication administration record and the client's arm band

Answer and Explanation

The Correct Answer is A

A. Documents medication administration prior to administering it: Documenting medication administration before actually administering it is incorrect and can lead to errors in documentation. The nurse should document medication administration after ensuring the medication is given to the client.

B. Verifies the medication against the prescription and medication label: This is a correct action. The nurse should verify the medication against the prescription and medication label to ensure accuracy before administering it.

C. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct action. The nurse should check the provider's orders and confirm the dosage in a reliable medication reference guide to ensure accuracy before administering the medication.

D. Scans the barcode on the medication administration record and the client's armband: This is a correct action. Scanning the barcode on the medication administration record and the client's armband helps ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.

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Correct Answer is A

Explanation

A. "I'll be glad when I can stop taking this medicine.": This statement indicates a misunderstanding about phenytoin therapy. Phenytoin is typically a long-term medication used to prevent seizures, and it is not typically discontinued unless under the guidance of a healthcare provider. The nurse should clarify that stopping the medication abruptly can lead to rebound seizures and should emphasize the importance of continuing the medication as prescribed.

B. "I have made an appointment to see my dentist next week.": This statement indicates appropriate understanding, as regular dental check-ups are important for individuals taking phenytoin due to the medication's potential side effect of gingival hyperplasia.

C. "I know that I cannot switch brands of this medication.": This statement demonstrates understanding, as different brands of phenytoin can have variations in bioavailability, which can affect seizure control. It is important for clients to remain consistent with the same brand or formulation unless directed otherwise by their healthcare provider.

D. "I will notify my doctor before taking any other medications.": This statement indicates understanding of the potential for drug interactions with phenytoin, as it is a hepatic enzyme inducer and can affect the metabolism of other medications. Clients should always consult their healthcare provider before taking any new medications or supplements to ensure compatibility with phenytoin therapy.

A. Insert the needle slowly and gently. B. Pull the skin 1.3 cm (1/2 inch) to the side. C. Aspirate for 5 to 10 seconds. D. Use a 45° angle of insertion.

Correct Answer is B

Explanation

A. Insert the needle slowly and gently.

This statement is generally true for most injection techniques, including the Z-track method. Slow and gentle insertion helps minimize discomfort for the client and allows for better control over the needle's placement. However, the specific speed of insertion may vary depending on the nurse's technique and the client's skin condition.

B. Pull the skin 1.3 cm (1/2 inch) to the side.

This statement is correct. The Z-track technique involves pulling the skin laterally (to the side) by approximately 1.3 cm (1/2 inch) before inserting the needle. This lateral displacement of the skin creates a zigzag pathway for the medication, which helps prevent leakage or tracking of the medication along the injection site.

C. Aspirate for 5 to 10 seconds.

Aspiration, or pulling back on the plunger of the syringe after needle insertion, is not typically recommended for intramuscular injections, including those using the Z-track method. Aspiration may increase the risk of tissue trauma or damage to blood vessels. Since the Z-track technique is designed to minimize medication leakage into the subcutaneous tissue, aspiration is usually unnecessary.

D. Use a 45° angle of insertion.

The angle of insertion for the Z-track technique is typically 90 degrees (perpendicular) to the skin surface rather than 45 degrees. This angle allows for proper depth penetration into the muscle and ensures adequate delivery of the medication into the muscle tissue.

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A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is A

Explanation

A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following is an appropriate action during this procedure?

Correct Answer is B

Explanation

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A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?