A nurse is reviewing a client's medication administration record (MAR). The nurse notices that a medication that was due at 0900 has not been given. It is now 1030. What should the nurse do first?

Check if another nurse has given the medication

Give the medication as soon as possible

Document why the medication was delayed

Report the incident to the charge nurse

Answer and Explanation

The Correct Answer is A

The first step in managing a missed or delayed medication is to check if another nurse has given or withheld the medication for some reason. This can prevent duplicate or omitted doses and ensure continuity of care. The nurse should also check if there are any contraindications or changes in orders for giving the medication.

Incorrect choices:

b) Give the medication as soon as possible: Giving the medication as soon as possible may be appropriate, but it is not the first action. The nurse should verify if another nurse has given or withheld the medication before administering it.

c) Document why the medication was delayed: Documenting why the medication was delayed is important, but it is not the first action. The nurse should verify if another nurse has given or withheld the medication and give it if indicated before documenting.

d) Report the incident to the charge nurse: Reporting the incident to the charge nurse may be necessary, but it is not the first action. The nurse should verify if another nurse has given or withheld the medication and give it if indicated before reporting.

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Correct Answer is B

Explanation

When mixing two types of insulin in one syringe, the nurse should follow the mnemonic RN or "regular before NPH". This means that the nurse should first inject air into the NPH vial, then inject air into the regular vial, then withdraw regular insulin from the vial, and finally withdraw NPH insulin from the vial. This order prevents contamination of the regular insulin with NPH insulin and ensures accurate dosing.

Incorrect choices:

a) Inject air into the NPH vial: This is correct, but it is not the next action. The nurse should inject air into the NPH vial before drawing up any insulin.

c) Withdraw NPH insulin from the vial: This is incorrect and can lead to a medication error. The nurse should withdraw NPH insulin after withdrawing regular insulin.

d) Withdraw regular insulin from the vial: This is correct, but it is not the next action. The nurse should inject air into the regular vial before withdrawing regular insulin.

A. Take the medication with food B. Monitor your pulse rate daily C. Avoid drinking grapefruit juice D. All of the above

Correct Answer is D

Explanation

All of the instructions are correct and important for a client who is taking digoxin. Digoxin is a cardiac glycoside that can improve the contractility and rhythm of the heart. However, it can also cause serious side effects, such as bradycardia, arrhythmias, or toxicity.

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A nurse is reviewing a client's medication administration record (MAR). The nurse notices that a medication that was due at 0900 has not been given. It is now 1030. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer insulin to a client with diabetes mellitus. The nurse draws up 10 units of regular insulin and 20 units of NPH insulin in the same syringe. Which of the following actions should the nurse take next?

Correct Answer is B

Explanation

A nurse is teaching a client who has a new prescription for digoxin. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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