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 ["A","D"]

Explanation

A. Establishing a regular sleep schedule helps regulate the body's internal clock, making it easier to fall asleep and wake up at the desired times. Consistency in sleep patterns can improve sleep quality and overall sleep hygiene.
D. Avoiding caffeinated beverages late in the day, particularly in the afternoon and evening, helps prevent interference with the natural sleep-wake cycle. Caffeine is a stimulant that can disrupt sleep by delaying the onset of sleep and reducing total sleep time.
B. While medications may be prescribed for sleep disturbances in some cases, they are typically reserved for short-term use and under the guidance of a healthcare provider.
C. Consuming alcohol close to bedtime can disrupt sleep patterns and lead to poorer sleep quality. While warm beverages such as herbal tea or warm milk may promote relaxation, alcohol is not recommended as a sleep aid.
E. While a short nap earlier in the day may be beneficial for some individuals, especially if they are experiencing daytime sleepiness, taking an afternoon nap can disrupt nighttime sleep patterns and worsen insomnia.

Correct Answer is []

Explanation

Pressure sores are divided into different stages:

Stage 1= Intact skin with non-blanchable redness over a localized area

Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base

Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed

Stage 4- Full thickness wound with exposed tendons, muscle and bone

Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue

The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.

Nutritional status determines the risk of developing pressure injury and the chances of wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["A","D"]

Explanation

Correct Answer is []

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication mg/mL vial. Which action should the nurse perform with the remainder of the medication?

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

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

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 client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

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?