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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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Neuropathy can lead to decreased sensation in the feet, making the client less aware of potential injuries or skin breakdown. As a result, there is an increased risk for impaired skin integrity, including the development of pressure ulcers, blisters, or wounds. Promoting foot care is essential to prevent complications such as foot ulcers or infections.
A. Neuropathy can compromise the body's ability to detect injuries or wounds in the feet, increasing the risk of infection if injuries go unnoticed or untreated. However, while infection is a concern, the primary issue with neuropathy-related foot care is the risk of impaired skin integrity.

C. While self-care deficits may be addressed as part of the client's overall care plan, it is not the priority at this time compared to preventing skin breakdown and potential complications.
D. While impaired mobility may contribute to increased pressure on the feet and potential skin breakdown, the priority is addressing the immediate risk of impaired skin integrity due to neuropathy- related sensory deficits.

A. Enlisting security personnel to assist with restraining the client. B. Administering the medication to a client behind a closed curtain. C. Placing a client in restraints without having a healthcare provider's order. D. Informing a client that the medication being administered is a vitamin.

Correct Answer is C

Explanation

C. A tort is a wrongful act or an infringement of a right that leads to civil legal liability. Restraint use should be based on a healthcare provider's order and should follow institutional policies and procedures. Administering restraints without proper authorization can result in legal liability, as it may constitute false imprisonment or battery.
A. In an emergency situation where a client is agitated and poses a risk to themselves or others, it may be necessary to enlist security personnel to help ensure the safety of everyone involved.
B. Administering medication behind a closed curtain is a common practice to provide privacy and confidentiality to the client.
D. Intentionally misleading a client about the nature of the medication being administered constitutes a form of deceit or fraud. However, this is not considered a tort.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

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)]

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?