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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. "I have headaches in the evening.": Headaches associated with sleep apnea typically occur in the morning due to nocturnal hypoxia and carbon dioxide retention, not in the evening. Evening headaches are not a common presenting symptom.

B. "I feel rested upon wakening.": Clients with sleep apnea often experience non-restorative sleep and wake feeling tired or unrefreshed. Feeling rested upon waking would not be expected in untreated sleep apnea.

C. "I feel alert during the day.": Daytime sleepiness is a hallmark symptom of sleep apnea due to fragmented sleep and oxygen desaturation. Feeling alert would not align with the typical presentation.

D. "My spouse says I snore.": Loud, habitual snoring is a common and expected symptom of obstructive sleep apnea. It is often reported by bed partners and is an important clinical clue for diagnosis.

A. Use a 3 mL syringe to flush the catheter. B. Cleanse the port with povidone-iodine prior to obtaining the specimen. C. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample. D. Instruct the client to perform the Valsalva maneuver during the blood draw.

Correct Answer is D

Explanation

A. Use a 3 mL syringe to flush the catheter: Small syringes (3 mL) create high pressure that can damage the lumen of a peripherally inserted central catheter (PICC). Larger syringes, typically 10 mL or greater, are recommended to safely flush and maintain catheter integrity.

B. Cleanse the port with povidone-iodine prior to obtaining the specimen: Current guidelines recommend using an alcohol-based antiseptic (e.g., 70% isopropyl alcohol) rather than povidone-iodine for cleaning catheter hubs due to faster action and reduced contamination risk.

C. Flush with 20 mL of 0.9% sodium chloride after obtaining the blood sample: While flushing is required, the volume depends on the protocol and whether blood was drawn for lab testing. Immediate flushing with 10 mL is often sufficient; 20 mL may be excessive unless the protocol specifies.

D. Instruct the client to perform the Valsalva maneuver during the blood draw: Performing the Valsalva maneuver increases intrathoracic pressure and reduces the risk of air embolism when accessing a central line. This is a recommended safety measure during blood draws from PICC lines.

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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?

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