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 D

Explanation

A high INR indicates that the client is at risk of bleeding due to excessive anticoagulation. The nurse should first assess for signs of bleeding, such as bruising, petechiae, hematuria, or melena.

Then, the nurse should notify the provider and follow orders to reverse the anticoagulation effect, such as administering vitamin K or fresh frozen plasma.

Holding the next dose of warfarin may be appropriate, but it is not the priority action.

Incorrect choices:

a) Administer vitamin K: Vitamin K is an antidote for warfarin overdose, but it should not be given without a provider's order. It may also take several hours to reverse the anticoagulation effect.

b) Notify the provider: Notifying the provider is an important step, but it is not the first action. The nurse should assess the client's condition before calling the provider.

c) Hold the next dose of warfarin: Holding the next dose of warfarin may prevent further anticoagulation, but it does not address the current risk of bleeding. The nurse should assess and intervene for bleeding before holding the medication.

A. Flush the tube with 30 mL of water B. Check the placement of the tube C. Clamp the tube for 30 minutes D. Elevate the head of the bed

Correct Answer is B

Explanation

The nurse should check the placement of the tube before administering any medication or fluid via an NG tube. This can prevent aspiration, infection, or injury to the client. The nurse can check the placement by aspirating gastric contents and measuring the pH, or by using a carbon dioxide detector.

Incorrect choices:

a) Flush the tube with 30 mL of water: Flushing the tube with water is correct, but it is not the next action. The nurse should flush the tube before and after administering the medication to prevent clogging and ensure delivery.

c) Clamp the tube for 30 minutes: Clamping the tube for 30 minutes is incorrect and can cause complications. The nurse should not clamp the tube unless ordered by the provider. Clamping the tube can increase the risk of reflux, aspiration, or tube displacement.

d) Elevate the head of the bed: Elevating the head of the bed is correct, but it is not the next action. The nurse should elevate the head of the bed at least 30 degrees before and during the administration of the medication to prevent aspiration and promote gastric emptying.

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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

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Explanation

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Correct Answer is B

Explanation

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