A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?
Nitroglycerin transdermal was applied to a client’s chest.
Cefotaxime was administered to a client after obtaining blood cultures.
Digoxin was administered to a client who has a heart rate of 64/min.
Insulin lispro was administered to a client immediately before bed.
The Correct Answer is D
Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.
Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.
Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.
Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Blood glucose 130 mg/dL.
This is because the normal range of blood glucose for pregnant women is 70 - 110 mg/dL .
A blood glucose level of 130 mg/dL indicates gestational diabetes, which can have adverse effects on the mother and the fetus.
The nurse should report this finding to the provider and initiate interventions such as dietary counseling, glucose monitoring, and insulin therapy if needed.
Choice A is wrong because WBC 7,000/mm³ is within the normal range for pregnant women, which is 4,500 to 10,000 cells/mcL .
A low WBC count would indicate an increased risk of infection, while a high WBC count would indicate inflammation or infection.
Choice B is wrong because hemoglobin 13 g/dL is within the normal range for pregnant women, which is 11 to 14 g/dL .
A low hemoglobin level would indicate anemia, while a high hemoglobin level would indicate dehydration or polycythemia.
Choice D is wrong because RBC 5.8 million/mm³ is within the normal range for pregnant women, which is 4.2 to 5.9 million/mm³ .
A low RBC count would indicate anemia or hemorrhage, while a high RBC count would indicate dehydration or polycythemia.
Correct Answer is A
Explanation
Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.
Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.
Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.
Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.
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