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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensure that the health care provider has consulted with another team member: While consultation may be part of ethical decision-making, it is not the primary action the nurse should take when a comatose client requires consent. The priority is confirming that informed consent is obtained from the appropriate decision-maker.
B. Ensure that the client's 16-year-old child supports the provider's decision for surgery: Minors cannot legally provide consent for medical procedures. The nurse should focus on the legal health care surrogate or guardian rather than the opinion of a minor child.
C. Determine if the procedure is medically necessary for the client: Assessing medical necessity is the provider’s responsibility. The nurse’s role is to advocate for the client by ensuring informed consent is obtained and the surrogate understands the procedure, risks, and benefits.
D. Determine if the health care surrogate understands the risks and benefits of the procedure: The nurse should confirm that the health care surrogate has received adequate information and understands the risks, benefits, and alternatives to the procedure. This ensures ethical and legal consent is obtained for a client unable to make decisions.
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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