Patient Data

Exhibits

The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose.

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

Compare the medication label to the order

Use at least 2 client identifiers before administering a dose

Document all medication in the electronic record as soon as it is given

Involve and educate clients in medication administration

Question unusually large or small doses F Double check all dosage calculations

Answer and Explanation

Correct Answer : C,D

Immediate documentation after drug administration ensures the everyone who comes into contact with the client is aware of what has already been done

Ensuring the client does the administration also avoids such errors. The client is able to understand and question when too many doses are given without proper explanation.

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Correct Answer is D

Explanation

D. Assessing the client's skin and mucous membranes can provide valuable information about oxygenation, circulation, and hydration status, which are relevant during and after nasopharyngeal suctioning. Changes in skin color, moisture, and mucous membrane appearance can indicate respiratory distress, hypoxia, or inadequate hydration.
A. Skin turgor assessment is typically used to evaluate hydration status and is not directly relevant to nasopharyngeal suctioning.
B. Bowel sounds assessment is not directly related to nasopharyngeal suctioning and is not a priority during this procedure.
C. Palpating pedal pulses is a method of assessing peripheral circulation and is not directly relevant to nasopharyngeal suctioning.

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

Correct Answer is B

Explanation

B. Hyperkalemia can lead to cardiac dysrhythmias, including bradycardia, heart block, or ventricular fibrillation, which can be life-threatening. Therefore, assessing the client's apical pulse rate and rhythm is crucial to identify any cardiac changes and promptly intervene if necessary.
A. Changes in urine output and characteristics may indicate renal involvement in hyperkalemia. However, monitoring urinary output alone may not provide immediate information about the client's cardiac status or the severity of hyperkalemia.
C. Assessing deep tendon reflexes is important in evaluating for neurological manifestations of hyperkalemia. However, changes in reflexes may not be immediately indicative of the severity of hyperkalemia or its potential cardiac effects.
D. Assessing muscle strength is important in evaluating for neuromuscular manifestations of hyperkalemia, changes in muscle strength may not provide immediate information about the client's cardiac status or the severity of hyperkalemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

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

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

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?

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