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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors and increases the risk of bleeding. The client should use a soft-bristled toothbrush and an electric razor to prevent trauma and bleeding from minor cuts or abrasions.

A) Correct. This statement indicates that the client understands how to prevent bleeding while taking warfarin.

B) This statement indicates a lack of understanding of the teaching. The client should avoid sudden changes in vitamin K intake, as this can affect the therapeutic level of warfarin and increase the risk of clotting or bleeding. Green leafy vegetables are high in vitamin K and should be consumed in consistent amounts.

C) This statement indicates a lack of understanding of the teaching. The client should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen while taking warfarin, as they can increase the risk of bleeding. The client should consult with the provider before taking any over-the-counter medications for pain relief.

D) This statement indicates a lack of understanding of the teaching. Warfarin does not affect blood pressure directly but rather affects blood clotting. The client should monitor their international normalized ratio (INR), which measures the effectiveness of warfarin, regularly while taking this medication.

A. Stop the infusion and notify the provider. B. Decrease the infusion rate and notify the provider. C. Increase the infusion rate and notify the provider. D. Continue the infusion and monitor the client.

Correct Answer is B

Explanation

Heparin is an anticoagulant that inhibits clotting factors and prevents thrombus formation. The aPTT is a laboratory test that measures the effectiveness of heparin therapy. The therapeutic range for aPTT is usually 1.5 to 2 times the normal value, which is about 25 to 35 seconds. If the aPTT is above the therapeutic range, this indicates that the client is at risk for bleeding and that the heparin dose is too high.

A) This is not an appropriate action. Stopping the infusion abruptly could put the client is at risk for clotting and complications such as pulmonary embolism or stroke The nurse should only stop the infusion if instructed by the provider or if the client has signs of severe bleeding or haemorrhage.

B) Correct. This is an appropriate action. Decreasing the infusion rate will lower the heparin dose and bring the aPTT back to the therapeutic range. The nurse should notify the provider of the aPTT result and obtain further orders for heparin therapy.

C) This is not an appropriate action. Increasing the infusion rate will raise the heparin dose and increase the aPTT further above the therapeutic range. This could worsen the risk of bleeding for the client.

D) This is not an appropriate action. Continuing the infusion without adjusting the rate or notifying the provider could result in harm to the client due to excessive anticoagulation and bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 nurse is teaching a client who has a new prescription for warfarin about safe medication practices. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A client is receiving a continuous intravenous infusion of heparin for deep vein thrombosis. The nurse notes that the client's activated partial thromboplastin time (aPTT) is above the therapeutic range. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is administering an intramuscular injection to a client. Which of the following actions should the nurse take to prevent medication errors?

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?

A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take to ensure medication safety? (Select all that apply.)

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

A nurse is reviewing a client's medication list and notices that the client is taking two medications that have a potential interaction. Which of the following actions should the nurse take?