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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Record a palpable systolic pressure of 90 mm Hg is premature because the nurse has not yet completed the process of determining the systolic blood pressure.

B. Inflate blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse disappears to ensure accurate measurement of the systolic blood pressure.

C. Release the manometer valve immediately would not allow the nurse to accurately determine the systolic blood pressure. The valve should be released slowly to palpate the return of the pulse.

D. Document the absence of the radial pulse is unnecessary because the disappearance of the pulse is a normal part of the procedure when obtaining a systolic blood pressure by palpation.

A. Turgor. B. Blood pressure. C. Weight. D. Lung sounds.

Correct Answer is C

Explanation

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Correct Answer is C

Explanation

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