Patient Data

Exhibits

Review was done of H and P, nurses' notes, and orders.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition:

Stage 1 Pressure Injury: This is the most likely diagnosis based on the description of a partial thickness abrasion.

Actions to Take:

Clean the area with sterile saline or wound cleanser and dry: This is essential to prevent infection.

Place a hydrocolloid dressing over the area: A hydrocolloid dressing helps to protect the area and maintain a moist wound environment which promotes healing.

Parameters to Monitor:

Skin integrity: Close monitoring of the wound is crucial to assess healing and prevent worsening.

Temperature: An increase in temperature could indicate an infection.

Nursing Test Bank

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Correct Answer is B

Explanation

Specific gravity of 1.035 is elevated and reflects more concentrated urine. This higher value is more indicative of significant dehydration. Since the client has been vomiting and experiencing diarrhea for several days and has difficulty tolerating oral fluids, this value would suggest a state of more severe dehydration, where the body is conserving water and the urine becomes highly concentrated.

A. Involve and educate clients in medication administration B. Question unusually large or small doses C. Document all medication in the electronic record as soon as it is given D. Double check all dosage calculations E. Use at least. 2 client identifiers before administering a dose F. Compare the medication label to the order

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

Explanation

C) Document all medication in the electronic record as soon as it is given - This would have prevented the primary nurse from administering a second dose of insulin. The root cause of the error was a failure to document the medication administration in the electronic health record. Had the covering nurse documented the insulin administration immediately, the primary nurse would have seen that the medication had already been given, preventing the overdose.

E) Use at least 2 client identifiers before administering a dose - While this might not have prevented this specific error, it is a crucial safety measure to prevent medication errors to the wrong patient. Using two client identifiers is a standard safety practice to ensure medications are given to the correct patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

Correct Answer is B

Explanation

Patient Data Exhibits What medication error prevention techniques would have helped to avoid this error? Select all that apply.

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

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a fort?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.