A nurse is caring for a client.
Exhibits
The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?
Propranolol
Pantoprazole
Lovastatin
Morphine
The Correct Answer is A
A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Implementing a recorded order message is not a standard practice and may not be permissible in all healthcare settings.
B. Transcribing the order into the client's health record is essential to ensure accurate documentation.
C. Repeating the order back to the provider ensures that the nurse has correctly understood the prescription.
D. Questioning any part of the order that is unclear or inappropriate ensures patient safety and accuracy.
E. While obtaining the provider's signature is necessary, the timeframe may vary depending on facility policies and regulations. The focus should be on ensuring the accuracy and clarity of the order first.
Correct Answer is B
Explanation
A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.
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