A client is admitted with reports of shortness of breath, dyspnea on exertion, and chest pressure. The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. Which action should the nurse take?

Give the dosage recommended in the drug handbook.

Consult pharmacist for dose clarification.

Administer the medication as prescribed.

Verify the prescribed dosage with healthcare provider.

Answer and Explanation

The Correct Answer is D

D. When encountering a medication dosage that appears unusually large or different from what is expected, the nurse should always verify the prescription with the healthcare provider before administering the medication. This step ensures patient safety and helps prevent medication errors.

A. Giving the dosage recommended in the drug handbook may not be appropriate if the prescribed dosage differs significantly from the usual or recommended dosage due to patient- specific factors or other considerations.

B. In situations where the prescribed dosage seems unusually large or different from the usual guidelines, it is essential to confirm with the healthcare provider who wrote the prescription to ensure accuracy and appropriateness for the specific patient.

C. Administering the medication as prescribed without further clarification could potentially lead to harm if the prescribed dosage is incorrect or inappropriate for the patient's condition.

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Correct Answer is B

Explanation

A. Using an oral airway can be appropriate in some situations to keep the mouth open and facilitate oral care, especially in an unconscious client. This helps prevent biting and allows for easier access to the oral cavity. Therefore, this action does not indicate a need for additional training.

B. Placing an unconscious client in a supine position for oral care can be inappropriate, as it increases the risk of aspiration, especially if there are secretions in the mouth. It is generally safer to position the client in a lateral position to minimize this risk. This action may indicate a need for additional training.

C. Testing for a gag reflex before performing oral care is a standard precaution, especially for unconscious clients. This helps prevent aspiration and ensures the safety of the client during the procedure.

D. Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration, especially for unconscious clients who may have difficulty managing their secretions.

A. Blood pressure. B. Pulse rate. C. Respiratory rate. D. Temperature.

Correct Answer is C

Explanation

C. When a client is observed using accessory muscles, it suggests increased effort in breathing, which may indicate respiratory distress or compromise. Therefore, the first vital sign the nurse should obtain is the respiratory rate to assess the client's breathing pattern and adequacy of ventilation.

A, B and D are important vitals signs in all clients. However, respiratory rate is of more concern in a client with signs of respiratory distress (use of accessory muscles).

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

Correct Answer is C

Explanation

Following surgery, a client expresses concern to the nurse about being able to use the bedpan. After noting that the client's prescribed postoperative activity includes getting up to a chair three times a day, how should the nurse intervene?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?