A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse make?
"I recommend that you take this medication as prescribed."
"I will call the pharmacist now to check on this medication."
"Did the doctor discuss with you that there was a change in this medication?"
"Do you know why this medication is being prescribed for you?"
The Correct Answer is B
Rationale:
A. "I recommend that you take this medication as prescribed.": This response dismisses the client’s concern and does not address the possibility of a medication error. It can also undermine trust and ignores the need for verification before administration.
B. "I will call the pharmacist now to check on this medication.": This is the most appropriate response because it prioritizes client safety by verifying the medication before administration. It also acknowledges the client’s concern and involves a qualified resource for confirmation.
C. "Did the doctor discuss with you that there was a change in this medication?": While this could provide insight into changes in therapy, it delays immediate verification and does not address the need to confirm the medication’s accuracy before giving it.
D. "Do you know why this medication is being prescribed for you?": This may promote client education, but it does not address the immediate safety concern or the need to verify the medication before administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urinary output 20 mL/hr: A urinary output less than 30 mL/hr in an adult indicates potential renal hypoperfusion or urinary retention. This is a priority finding that should be reported to the provider promptly.
B. Serous drainage on abdominal dressing: Serous drainage is a normal postoperative finding, indicating normal wound healing and fluid exudate. It does not require immediate provider notification.
C. Temperature 37.6° C (99.7° F): This temperature is slightly elevated but within the expected postoperative range due to the inflammatory response. It does not indicate an urgent complication.
D. Blood pressure 100/70 mm Hg: This blood pressure is within normal limits for many adults and is not necessarily concerning in a postoperative context unless accompanied by other symptoms such as tachycardia or dizziness.
Correct Answer is B
Explanation
Rationale:
A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.
B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.
C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.
D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.
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