A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?
Request a medication reconciliation form from the pharmacy.
Ask the client if she received the 1700 medication.
Contact the previous nurse to determine if the client received the medication.
Administer the medication and document the current time.
The Correct Answer is C
Choice A Reason:
Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.
Choice B Reason:
Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.
Choice C Reason:
Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.
It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.
Choice D Reason:
Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Administering sedative medication should not be the first action. It is important to assess the client's level of comfort and understand the reason for pulling on the NG tube before considering sedation. Sedation may mask underlying issues, and the goal is to address the cause of the behavior.
Choice B Reason:
Assessing the client's level of comfort is the priority. Understanding the reason for pulling on the NG tube is crucial before implementing interventions. The client may be experiencing pain, discomfort, anxiety, or another issue that needs to be addressed.
Choice C Reason:
Applying a restraint should be a last resort and is not the initial action. Restraints are used to ensure safety when other measures have failed. The priority is to address the underlying cause and promote comfort without resorting to restraint.
Choice D Reason:
Documenting the client's behavior is important for the medical record, but it comes after assessing and addressing the immediate needs of the client. Understanding the context and reasons for the behavior is crucial for accurate documentation.
Correct Answer is A
Explanation
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg." This statement demonstrates correct technique for ascending stairs with crutches. When going up stairs, the client should advance the crutches onto the step first, followed by the unaffected leg.
Choice B Reason:
"I should keep my elbows straight when I am walking with my crutches." The client should maintain a slight bend in the elbows while walking with crutches to provide stability and support.
Choice C Reason:
"I will support my weight on the hand grips of the crutches." The client should not support their weight on the hand grips alone; weight should be distributed through the hands and arms to avoid putting excessive pressure on the axillae.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off." It is generally not advisable to walk with crutches without shoes, as wearing shoes provides better support and stability. The client should wear supportive, non-skid footwear while using crutches.
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