A nurse is preparing to administer an IM medication to a client. The nurse is unfamiliar with this medication. Which of the following actions should the nurse take?
Check the medication label twice before administering it.
Review the client's medication reconciliation record.
Draw up the medication dose and ask the charge nurse to administer it.
Use a medication reference book to look up the medication.
The Correct Answer is D
A. Check the medication label twice before administering it: Verifying the label is an essential safety step, but it does not provide the nurse with information about the medication’s purpose, dosage, administration route, or potential side effects. This action alone is insufficient when unfamiliar with a drug.
B. Review the client's medication reconciliation record: Reviewing the reconciliation ensures the medication aligns with the client’s current prescriptions, but it does not provide information about how to safely administer a medication the nurse does not know.
C. Draw up the medication dose and ask the charge nurse to administer it: Delegating administration without first understanding the medication compromises client safety and violates the nurse’s responsibility to ensure safe administration. The nurse must gain knowledge before handling the medication.
D. Use a medication reference book to look up the medication: Consulting a reputable medication reference allows the nurse to obtain critical information about indications, dosage, side effects, contraindications, and administration guidelines. This step ensures safe and informed medication administration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Withdraw dose of regular insulin: Withdrawing the regular insulin dose is performed after the air has been injected into both vials and the NPH insulin has been drawn up if using the “clear before cloudy” technique. Doing this first would risk disrupting the proper sequence and potentially contaminating the insulin.
B. Inject air into the vial of regular insulin: Air must be injected into the regular insulin vial before withdrawing the medication, but this step is performed after first injecting air into the NPH vial according to the standard procedure for mixing insulins. Starting with the regular insulin vial would not follow the recommended order.
C. Inject air into the vial of NPH insulin: Injecting air into the NPH insulin vial first is the initial step when preparing a mixed insulin dose. This step equalizes pressure inside the vial, allowing for easier withdrawal later, and follows the correct sequence of “air into cloudy first, then clear,” which prevents contamination of the regular insulin.
D. Withdraw dose of NPH insulin: Withdrawing NPH insulin is done after the regular insulin has been drawn into the syringe to maintain the correct “clear before cloudy” technique. Doing this first could result in accidental mixing or contamination of the regular insulin.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Rationale:
• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.
• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.
• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.
• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.
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