A nurse administered ketorolac 30 mg IM to a client who is postoperative.
Which of the following information should the nurse document? (Select all that apply)

Gauge and length of needle.

Medication expiration date.

Dose of medication administered.

Site of injection.

Time of administration.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:

The gauge and length of needle used for an IM injection are important to document. This information can help track which supplies were used and can be useful for future reference.

Choice B rationale:

While it’s important to check the medication expiration date before administration, it’s not typically documented after administering medication.

Choice C rationale:

The dose of medication administered should always be documented. This helps ensure accurate medical records and allows healthcare providers to track how much of a medication a patient has received.

Choice D rationale:

The site of injection should be documented. This can help prevent complications such as repeated use of the same injection site.

Choice E rationale:

The time of administration should be documented. This helps keep track of when the patient received their medication, which is crucial for medications that need to be given at specific intervals.

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Correct Answer is C

Explanation

Choice A rationale:

Asking for a home phone number is not an effective method for identifying a patient. Phone numbers can be easily forgotten or mixed up, especially in a hospital setting where a patient may be under stress or experiencing health issues.

Choice B rationale:

Room numbers can change if the patient is moved, and other patients may have previously occupied the same room. Therefore, room numbers are not reliable identifiers.

Choice C rationale:

Asking the patient to confirm their own name is one of the most direct and reliable ways to verify their identity. This method respects patient autonomy and privacy while ensuring accurate identification.

Choice D rationale:

Age alone is not a reliable identifier because it does not distinguish between different patients of the same age.

A. Dry mouth. B. Nausea. C. Agitation. D. Dizziness.

Correct Answer is C

Explanation

Choice A rationale:

Dry mouth is a common side effect of diphenhydramine. Diphenhydramine is an antihistamine that is often used to treat allergies, insomnia, and symptoms of the common cold. It works by blocking the effects of histamine, a substance in the body that causes allergy symptoms. One of the effects of histamine is increased salivation, so when diphenhydramine blocks this effect, it can lead to dry mouth.

Choice B rationale:

Nausea is also a common side effect of diphenhydramine. This can occur because diphenhydramine can slow down the emptying of the stomach, leading to feelings of nausea. Additionally, diphenhydramine can affect the vestibular system in the inner ear, which can also lead to feelings of nausea.

Choice C rationale:

Agitation is considered an idiosyncratic reaction to diphenhydramine. An idiosyncratic reaction is an unusual or unexpected reaction to a drug that is not related to the usual pharmacological action of the drug. While diphenhydramine is typically used for its sedative effects, in some cases it can cause paradoxical central nervous system stimulation, leading to agitation.

Choice D rationale:

Dizziness is another common side effect of diphenhydramine. This occurs because diphenhydramine can affect the vestibular system in the inner ear, which plays a key role in maintaining balance. When this system is affected, it can lead to feelings of dizziness.

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A nurse administered ketorolac 30 mg IM to a client who is postoperative.Which of the following information should the nurse document? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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A nurse administered ketorolac 30 mg IM to a client who is postoperative.
Which of the following information should the nurse document? (Select all that apply)