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

A. Reviewing the advance directive is important but not the immediate priority in an acute situation.
B. Irrigating the nasogastric (NG) tube with water is not the priority action in this scenario.

C. Elevating the head does no address teh client's concern of choking and risk of apiration,
D. Performing oropharyngeal suctioning prevents aspiration of gastric content into the airway

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Encourage the use of incontinence briefs.

Correct Answer is B

Explanation

B. Assisting the client to a bedside commode after meals can help take advantage of the gastrocolic reflex, which typically stimulates bowel movements after eating. This timing may increase the likelihood of successful bowel evacuation and decrease the risk of soiling the bed and clothing.
A. Rectal tubes are sometimes used for bowel management in individuals with chronic fecal incontinence, but they are typically reserved for specific situations and are not commonly used as part of a routine bowel training regimen.
C. Glycerin suppositories are sometimes used to stimulate bowel movements in individuals with constipation, but they are not typically recommended as a routine intervention for managing fecal incontinence.
D. Incontinence briefs can help contain fecal soiling and minimize embarrassment associated with accidents but they do not address the underlying issues contributing to fecal incontinence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

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?

Correct Answer is B

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate. the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

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?

An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?

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?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?