The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

Inform the pharmacist who dispensed the medication.

Evaluate the client for symptoms of a drug overdose.

Report the medication error to the nursing supervisor.

Review the medication transcription with the nurse.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.

Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.

Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.

Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.

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Correct Answer is B

Explanation

Choice A Reason: Asking the client why he does not want to be weighed is not a priority action because it does not address the need to obtain his daily weight. The nurse should first try to find a way to weigh the client without causing him discomfort or distress.

Choice B Reason: This is the correct answer because weighing the client using a bed scale can avoid the need for

transferring him from the bed to a standing scale, which may be difficult or painful for him. The bed scale can provide an accurate measurement of his weight and help monitor his fluid status.

Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.

Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.

A. Caution the nurse that one more tardiness will result in probational employment. B. Offer to switch the nurse's shift assignments to afternoons or evenings. C. Stress the expectation that the nurse will arrive on time for all scheduled shifts. D. Have the nurse sign a copy of the hospital employee attendance policy.

Correct Answer is C

Explanation

Choice A Reason: Cautioning the nurse that one more tardiness will result in probational employment is not the best approach because it is too punitive and does not address the underlying cause of the tardiness. The nurse manager should first try to understand why the nurse is late and offer support or guidance if needed.

Choice B Reason: Offering to switch the nurse's shift assignments to afternoons or evenings is not the best approach because it may not solve the problem of tardiness and may create resentment among other staff members who have to adjust their schedules. The nurse manager should respect the nurse's preferences and availability but also hold the nurse accountable for fulfilling their responsibilities.

Choice C Reason: This is the best approach because it communicates clearly and respectfully what is expected of the nurse and why it is important for them to be punctual. The nurse manager should also provide feedback and recognition when the nurse improves their attendance.

Choice D reason: Having the nurse sign a copy of the hospital employee attendance policy is not the best approach because it may imply that the nurse is unaware or indifferent to the policy. The nurse manager should assume that the nurse knows and agrees with the policy, but may need some assistance or motivation to follow it.

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The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?

Nursing Test Bank

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