A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

When preparing the medication dosage

Directly before administering the medication

When reconciling counts of controlled substances

When removing the medication from the medication drawer

At the end of the shift

Answer and Explanation

Correct Answer : A,B,D

Correct responses:

A. When preparing the medication dosage: Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.

B. Directly before administering the medication: This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.

D. When removing the medication from the medication drawer: This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.

The other options are not directly related to verifying the medication administration record against the medication label:

C. When reconciling counts of controlled substances: This is important for ensuring accurate inventory but is not related to verifying medication administration.

E. At the end of the shift: This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.

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Correct Answer is C

Explanation

A. Request that another nurse check the client's BP in 30 min:

Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.

C. Recheck the client's BP in her other arm for comparison:

This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.

D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.

A. A feeling of swelling in the feet B. Pain at the injection site C. A sudden decrease in heart rate D. A sharp decrease in blood pressure

Correct Answer is D

Explanation

A. A feeling of swelling in the feet:

Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.

B. Pain at the injection site:

Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.

C. A sudden decrease in heart rate:

An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.

D. A sharp decrease in blood pressure:

This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.

Anaphylactic Shock: A life-threatening reaction | Henrylito D. Tacio

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A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?

Correct Answer is D

Explanation

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