Patient Data

Exhibits

The nurse pulled a bottle of potassium from the automated medication administration system. They went to the medication room to pull up the medication, and immediately went to the client's room to administer the dose. The nurse did not realize that they needed to calculate and pull the appropriate dose from the bottle and gave the entire volume for a total of 40 mEq. Which medication error prevention techniques would have helped to avoid this error? Select all that apply

Use at least 2 client identifiers before administering a dose

Document all medication as soon as it is given

Question unusually large or small doses

Double check the dosage of high risk medications with another nurse

Involve and educate clients in medication administration

Answer and Explanation

Correct Answer : C,D

A. Use at least 2 client identifiers before administering a dose – This is a critical step in preventing medication errors, but it would not have prevented the error in this scenario. The issue was with the dosage of the medication, not the identification of the client.
B. Document all medication as soon as it is given – While documentation is important for patient safety, it does not directly address the error of giving the wrong dose. Proper calculation and verification of the dose before administration are more effective in preventing this type of error.
C. Question unusually large or small doses – This is a key technique for preventing medication errors. The nurse should have questioned the unusually large dose of potassium, which was not calculated based on the client's weight and the prescribed amount. This would have alerted the nurse to the error before administering the medication.
D. Double check the dosage of high-risk medications with another nurse – Potassium is considered a high-risk medication, and double-checking the dosage with another nurse would have been an effective safety measure. This technique helps to catch errors in dosage calculations, especially with medications that have narrow therapeutic windows like potassium.
E. Involve and educate clients in medication administration – While involving and educating clients is important for overall safety and understanding, it is not a technique that would have helped prevent this particular medication error. The error was related to the nurse’s calculation and administration of the dose, not the client's involvement.

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Correct Answer is B

Explanation

A. Report any change in urine color is not a primary intervention in palliative care for this client. While monitoring urine output is important in assessing hydration status, it does not directly address the client's comfort, which is a key goal in palliative care.

B. Keep mucous membranes moist is a critical intervention for this client. Mouth breathing and the refusal of fluids can lead to dry mucous membranes, causing discomfort. Regular oral care using swabs or rinses can alleviate dryness, improving the client's comfort and quality of life.

C. Record the client's daily weight is unnecessary in this situation. Monitoring weight is typically relevant for clients whose fluid balance or nutritional status is being managed, which is not a focus in palliative care for a terminally ill client.

D. Maintain in high Fowler's position is not the priority in this scenario. While positioning may be adjusted to support breathing, the focus should remain on comfort, such as alleviating the dryness associated with mouth breathing.

A. Compare muscle strength bilaterally. B. Determine apical heart rate and rhythm. C. Observe color and amount of urine. D. Assess strength of deep tendon reflexes.

Correct Answer is B

Explanation

A. Compare muscle strength bilaterally is not the most immediate concern. Although muscle weakness is a potential sign of hypokalemia, the priority is assessing for cardiac complications, as potassium imbalances can cause life-threatening arrhythmias.

B. Determine apical heart rate and rhythm is the most important intervention. A potassium level of 2.5 mEq/L is dangerously low and can lead to life-threatening cardiac arrhythmias. The nurse should assess the heart rate and rhythm to detect any abnormalities such as bradycardia, tachycardia, or irregular rhythms, which are common in hypokalemia.

C. Observe color and amount of urine is not the priority. While renal function is important, the immediate concern in this case is the potential for severe cardiac complications due to the low potassium level.

D. Assess strength of deep tendon reflexes is important for detecting signs of hypokalemia, but it is secondary to assessing the heart, as potassium imbalances primarily affect cardiac function.

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Naxlex Comprehensive Predictor Exams

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit (ICU). The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

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