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

B. If the tip of the urinary catheter reemerges from the insertion site during insertion, it means that the catheter has become contaminated with microorganisms from the urethra or surrounding area. Continuing to insert the same catheter can introduce these microorganisms into the urinary tract, increasing the risk of urinary tract infection (UTI).

A. Increasing the lighting in the room allows for optimal visualization during the procedure, but it is not the priority action when the catheter has become contaminated.

C. Cleaning the catheter with providone-iodine is not sufficient to sterilize the catheter and eliminate the risk of introducing pathogens into the urinary tract.

D. Repositioning the legs before reinsertion does not address the contamination of the catheter and does not mitigate the risk of introducing pathogens into the urinary tract.

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 is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

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

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Which client assessment should the nurse perform during nasopharyngeal suctioning?

The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

The healthcare provider prescribes allopurinol 0.2 grams PO for a client with gout. The available medication is labeled, "Allopurinol tablets 200 mg." How many tablets should the nurse administer? (Enter numerical value only, rounded to the nearest whole number.)

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?