After an IV 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?

Document the event in the electronical health record.

Complete an incident report.

Inform the nurse on the next shift.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is B

A.   Document in the EHR: While documenting the event in the electronic health record is important, it's not sufficient to address the medication error. An incident report provides a more comprehensive and structured approach to documenting and investigating the event.
B.   When a medication error occurs, it's crucial to document the event through an incident report. This helps to identify the root cause of the error, prevent similar occurrences in the future, and ensure patient safety. An incident report should include a detailed description of the event, the actions taken, and any potential contributing factors.
C.   While informing the next shift is important for continuity of care, it's not the most immediate action needed to address the medication error. Completing an incident report is a higher priority.
D.   Notifying the healthcare provider is important, but it should be done in conjunction with completing an incident report. The incident report provides a detailed record of the event, which can be shared with the healthcare provider for further review and investigation.

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Correct Answer is A

Explanation

A. It's normal for the reservoir bag not to deflate completely during inspiration. A respiratory rate of 14 breaths/minute is within the normal range (12-20 breaths/minute). If the client is comfortable and their oxygen saturation is within the normal range, there is no need for intervention. Documenting the assessment data for future reference is sufficient.
B. Increasing the liter flow of oxygen may not be necessary if the client's oxygen saturation is within the normal range. It could also lead to oxygen toxicity if the flow is set too high.
C. Encouraging deep breaths may not be necessary if the client's respiratory rate is within the normal range.
D. Removing the mask to deflate the bag is not necessary and could interfere with the delivery of oxygen.

A. Ask the client how often episodes of sun downing are experienced. B. Assist the client with values clarification about end-of-life care options. C. Question the client about the frequency of falls in recent months. D. Request to have the client lie as still as possible for the assessment.

Correct Answer is C

Explanation

A. Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B. Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C. Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D. Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

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After an IV 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

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Correct Answer is C

Explanation

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