A nurse is reviewing a client's medication list and notices that the client is taking two medications that have a potential interaction. Which of the following actions should the nurse take?

Notify the provider and document the interaction in the client's chart.

Hold one of the medications and administer the other one as prescribed.

Administer both medications as prescribed and monitor the client for adverse effects.

Ask the client if they have experienced any problems with taking both medications.

Answer and Explanation

The Correct Answer is A

The nurse should notify the provider and document the interaction in the client's chart when a potential medication interaction is identified. The provider may need to adjust or change one or both of the medications to prevent if from harming the client.

A) Correct. This is the appropriate action for the nurse to take when a potential medication interaction is identified.

B) This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.

C) This is not an appropriate action. The nurse should not administer both medications as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.

D) This is not an appropriate action. The nurse should not rely on the client's self-report of problems with taking both medications. The client may not be aware of or recognize all of the possible signs and symptoms of a medication interaction.

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Correct Answer is B

Explanation

Heparin is an anticoagulant that inhibits clotting factors and prevents thrombus formation. The aPTT is a laboratory test that measures the effectiveness of heparin therapy. The therapeutic range for aPTT is usually 1.5 to 2 times the normal value, which is about 25 to 35 seconds. If the aPTT is above the therapeutic range, this indicates that the client is at risk for bleeding and that the heparin dose is too high.

A) This is not an appropriate action. Stopping the infusion abruptly could put the client is at risk for clotting and complications such as pulmonary embolism or stroke The nurse should only stop the infusion if instructed by the provider or if the client has signs of severe bleeding or haemorrhage.

B) Correct. This is an appropriate action. Decreasing the infusion rate will lower the heparin dose and bring the aPTT back to the therapeutic range. The nurse should notify the provider of the aPTT result and obtain further orders for heparin therapy.

C) This is not an appropriate action. Increasing the infusion rate will raise the heparin dose and increase the aPTT further above the therapeutic range. This could worsen the risk of bleeding for the client.

D) This is not an appropriate action. Continuing the infusion without adjusting the rate or notifying the provider could result in harm to the client due to excessive anticoagulation and bleeding.

A. Check the medication label against the medication administration record (MAR) three times. B. Ask the client to state their name and date of birth before giving the medication. C. Use a barcode scanner to verify the client's identification band and the medication. D. Document the medication administration after completing other tasks. E. Follow the six rights of medication administration.

Correct Answer is ["A","B","C","E"]

Explanation

The nurse should check the medication label against the MAR three times: before removing the medication from the storage area, before preparing or measuring the medication, and before administering the medication to the client.

The nurse should also ask the client to state their name and date of birth and use a barcode scanner to verify the client's identification band and the medication. These are methods of ensuring that the right medication is given to the right client.

The nurse should follow the six rights of medication administration: right client, right medication, right dose, right route, right time, and right documentation.

The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.

a) Correct. This is one of the methods of ensuring medication safety.

b) Correct. This is another method of ensuring medication safety.

c) Correct. This is a third method of ensuring medication safety.

d) Incorrect. The nurse should document the medication administration as soon as possible after giving the medication, not after completing other tasks.

e) Correct. This is a general principle of medication safety.

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