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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased respiratory rate: Naloxone is an opioid antagonist that rapidly reverses the effects of opioid overdose, including respiratory depression, sedation, and hypotension. The primary goal of naloxone administration is to restore adequate breathing by increasing the respiratory rate.
B. Decreased pain level:Naloxone reverses opioid effects, which means it can bring back pain that was previously managed by morphine. The client may experience increased pain, not a decrease.
C. Increased sedation:Naloxone reverses sedation, so the client is more likely to become alert and possibly agitated, rather than more sedated.
D. Decreased blood pressure: Morphine can cause hypotension, but naloxone reverses opioid-induced effects, which may result in a rise in blood pressure rather than a decrease.
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.
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