A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?

Check the client's identification band.

Explain the purpose and side effects of the medication.

Compare the medication label with the medication administration record (MAR).

Assess the client for contraindications and allergies.

Answer and Explanation

The Correct Answer is C

The nurse should follow the six rights of medication administration, which include the right client, right medication, right dose, right route, right time, and right documentation. The first action the nurse should take is to compare the medication label with the MAR to ensure that they match and that the medication has been prescribed for the client.

A) This is an important action, but not the first one. The nurse should check the client's identification band after comparing the medication label with the MAR and before administering the medication.

B) This is an important action, but not the first one. The nurse should explain the purpose and side effects of the medication after comparing the medication label with the MAR and before administering the medication.

C) Correct. This is the first action the nurse should take to ensure that the right medication is being given to the right client.

D) This is an important action, but not the first one. The nurse should assess the client for contraindications and allergies after comparing the medication label with the MAR and before administering the medication.

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Correct Answer is A

Explanation

The nurse should stop the infusion and remove the IV catheter as soon as possible if phlebitis is suspected. Phlebitis is inflammation of a vein that can be caused by mechanical, chemical, or infectious factors. Potassium chloride is a vesicant medication that can cause severe tissue damage if it extravasates into the surrounding tissues.

The nurse should apply a warm compress to the infusion site after removing the IV catheter to reduce inflammation and discomfort. The nurse should notify the provider and obtain an order for a different IV site to continue the infusion of potassium chloride at a different location. The nurse should not slow down the infusion rate and monitor the client because this could worsen the condition and increase the risk of complications.

b) Incorrect. This is an appropriate action after removing the IV catheter, but not before.

c) Incorrect. This is an appropriate action after removing the IV catheter and applying a warm compress, but not before.

d) Incorrect. This is not an appropriate action because it could worsen the condition and increase the risk of complications.

A. Notify the provider and document the interaction in the client's chart. B. Hold one of the medications and administer the other one as prescribed. C. Administer both medications as prescribed and monitor the client for adverse effects. D. Ask the client if they have experienced any problems with taking both medications.

Correct Answer is A

Explanation

The nurse should notify the provider and document the interaction in the client's chart when a potential medication interaction is identified. The provider may need to adjust or change one or both of the medications to prevent if from harming the client.

A) Correct. This is the appropriate action for the nurse to take when a potential medication interaction is identified.

B) This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.

C) This is not an appropriate action. The nurse should not administer both medications as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.

D) This is not an appropriate action. The nurse should not rely on the client's self-report of problems with taking both medications. The client may not be aware of or recognize all of the possible signs and symptoms of a medication interaction.

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A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving an intravenous (IV) infusion of potassium chloride. The nurse notices that the infusion site is red, swollen, and painful. The nurse suspects that the client has developed phlebitis. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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