After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Notify the healthcare provider.

Document the event on the chart.

Complete an incident report.

Inform the nurse on the next shift.

Answer and Explanation

The Correct Answer is A

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

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Correct Answer is C

Explanation

Choice A: Limitations to range of motion are not directly related to the application of a heating pad. A heating pad may help reduce pain and stiffness, but it does not affect the range of motion itself.

Choice B: Muscle strength and tone are also not directly related to the application of a heating pad. A heating pad may relax tense muscles, but it does not affect the strength or tone of the muscles.

Choice C: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad.

Choice D: Presence of rebound phenomenon is not relevant to the application of a heating pad. Rebound phenomenon refers to the worsening of symptoms after discontinuing a medication or treatment. A heating pad does not cause rebound phenomenon.

A. Abdominal girth. B. Bowel sounds. C. Vital signs. D. Breath sounds.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because abdominal girth can indicate the presence of fecal impaction, but it does not reflect the client's hemodynamic status or potential complications of the procedure.

Choice B Reason: This is incorrect because bowel sounds can indicate the level of bowel motility, but they do not provide information about the client's cardiovascular or respiratory function.

Choice C Reason: This is correct because vital signs can indicate the client's baseline condition and any changes during or after the procedure. Digital removal of a fecal impaction can stimulate the vagus nerve and cause bradycardia, hypotension, or cardiac arrest.

Choice D Reason: This is incorrect because breath sounds can indicate the client's respiratory status, but they are not directly affected by the procedure. However, breath sounds should be monitored for signs of aspiration if the client receives sedation or analgesia.

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After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is C

Explanation

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Correct Answer is C

Explanation

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Which equipment should the nurse use to measure a 5 mL dose of viscous liquid solution most accurately to be administered orally?

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that apply.)

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?

A client with a prescription for morphine sulfate 0.2 mg intravenously every 4 hours as needed for pain reports that pain is a 10 out of 10 on the numeric pain scale one hour after receiving the last administration. Which intervention should the nurse implement?

While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?