A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Withdraws the medication from the ampule using a subcutaneous needle

Breaks the top of the ampule using an antiseptic wipe

Disposes of the ampule by placing it in a sharp’s container

Performs 3 checks of the medication before administration

Answer and Explanation

The Correct Answer is A

Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.

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Correct Answer is D

Explanation

Choice A Reason:
Completing an incident report is inappropriate. While completing an incident report is important for documenting any errors or deviations from the standard of care, it should not be the first action taken. Assessing the client's condition takes precedence to ensure their immediate safety and well-being.
Choice B Reason:
Notifying the provider is inappropriate. Notifying the provider may be necessary, but it should not be the first action taken. Initially, the nurse should assess the client's condition to determine if any adverse effects have occurred as a result of the additional medication dose.
Choice C Reason:
Informing the nursing supervisor is inappropriate. Informing the nursing supervisor may be appropriate, especially if further actions or investigations are needed. However, the immediate priority is to assess the client's condition to ensure their safety.
Choice D Reason:
Observing the client's condition is appropriate. The nurse should first assess the client's condition to determine if any adverse effects have occurred due to the additional medication dose. This assessment helps identify any immediate concerns that require intervention. Based on the client's condition, further actions such as notifying the provider or completing an incident report may be warranted. However, observing the client's condition is the initial and most immediate action to take.

A. "I will wear a cover gown when caring for a client who has herpes simplex." B. "I will place a client who requires protective isolation in a negative airflow room." C. "I will wear an N95 respirator mask when caring for a client who is on contact precautions." D. "I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile."

Correct Answer is A

Explanation

Choice A Reason:
Herpes simplex virus (HSV) requires contact precautions when there are active lesions. Wearing a cover gown helps prevent the transmission of the virus through direct contact with the client or contaminated surfaces, indicating proper understanding of isolation guidelines.

Choice B Reason:
Protective isolation (also known as reverse isolation) is used for clients who are immunocompromised, and they require a positive airflow room, not a negative airflow room. Positive airflow rooms help keep contaminants out, while negative airflow rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
An N95 respirator mask is required for airborne precautions (e.g., for tuberculosis, measles, or varicella) rather than contact precautions. Contact precautions generally involve wearing gloves and a gown, but an N95 mask is not necessary.

Choice D Reason:
For clients with Clostridium difficile (C. difficile) infection, soap and water must be used for hand hygiene, not alcohol-based hand cleansers. Alcohol-based hand sanitizers are not effective against C. difficile spores, so proper handwashing with soap and water is essential to prevent the spread of this infection.

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A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

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