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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason:

To an insurance agency in regard to a life insurance policy . This situation is incorrect. Generally, disclosure of health information to an insurance agency requires the client's written consent.

Choice B Reason:

To a medical interpreter service on behalf of a client. This situation is correct. In healthcare settings, it is generally acceptable to share limited health information with a medical interpreter service to facilitate communication with the client, especially if the client has limited proficiency in the primary language spoken in the healthcare setting. The interpreter is bound by confidentiality rules similar to healthcare providers.

Choice C Reason:

To a family member when the client is not available. This situation is incorrect. Disclosing health information to a family member typically requires the client's consent unless there are specific circumstances, such as emergencies, where the healthcare provider may need to act in the best interest of the client.

Choice D Reason:

To an employer for a pre-employment screening. This situation is incorrect. Disclosing health information to an employer typically requires the client's written consent. Employment-related health information is usually protected by privacy laws.

A. Rub the puncture site with an alcohol pad. B. Apply firm pressure to the puncture site. C. Wrap the client's hand in a warm washcloth. D. Have the client raise his hand.

Correct Answer is C

Explanation

Choice A Reason:

Rubbing the puncture site with an alcohol pad is inappropriate. Rubbing the puncture site with an alcohol pad can cause vasoconstriction and make it more difficult to obtain a blood sample.

Choice B Reason:

Applying firm pressure to the puncture site is inappropriate. Applying firm pressure can further reduce blood flow to the puncture site, making it more challenging to collect an adequate blood sample.

Choice C Reason:

Wrapping the client's hand in a warm washcloth is appropriate. Applying a warm compress to the puncture site can help dilate the blood vessels and improve blood flow, making it easier to obtain a sufficient blood sample. This is especially beneficial for older adults who may have reduced blood flow to the extremities.

Choice D Reason:

Having the client raise his hand is inappropriate. Raising the hand may not be as effective as applying a warm washcloth in promoting blood flow to the puncture site. The warm washcloth helps to encourage vasodilation and improve the chances of obtaining an adequate blood sample.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations nurse disclose health information without the client's written consent?

Correct Answer is B

Explanation

A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A nurse is caring for a client who is scheduled for a CT scan that requires contrast dye. Which of the following actions is the priority for the nurse to take?

A nurse is reinforcing discharge instructions with a client who is walking with crutches. Which of the following statements by the client indicates an understanding of the instructions?

A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

A nurse is caring for a client who is terminally ill and has a do-not-resuscitate order on his medical record. The client asks, "What should I do if I have difficulty breathing?" Which of the following responses should the nurse make?

A nurse is assisting with the care of a client who has a closed chest tube drainage system. Which of the following actions should the nurse take?

A nurse is reinforcing discharge teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

A nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 15 cm (6 in), the nurse feels resistance and no urine flows through the catheter. Which of the following actions should the nurse take?