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 A

Explanation

Choice A reason: This client may have an infection or sepsis, which are life-threatening complications of surgery. The nurse should assess the client's vital signs, wound appearance, and laboratory results, and notify the physician immediately.

Choice B reason: This client has a chest tube to drain the pleural fluid and re-expand the lung. The amount of drainage is within normal limits and does not indicate an emergency. The nurse should monitor the client's respiratory status, oxygen saturation, and chest tube function.

Choice C reason: This client has a gunshot wound that may have caused tissue damage and bleeding. The dressing with 2 cm-sized dark red drainage may indicate fresh bleeding, but it is not excessive. The nurse should check the dressing for signs of infection, change it as ordered, and report any changes to the physician.

Choice D reason: This client has a Jackson-Pratt drain to collect the fluid from the surgical site after a mastectomy. The amount of serosanguineous fluid is expected and does not indicate a problem. The nurse should empty and measure the drain output, record it, and report any abnormalities to the physician.

A. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain. B. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute. C. After ambulating, a postoperative client grimaces and reports incisional pain at a "9 on a ten-point scale". D. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.

Correct Answer is C

Explanation

Choice A Reason: This client may need another dose of hydromorphone if the pain is not relieved by the previous one. A PN can administer this medication under the supervision of a RN and monitor the client's response.

Choice B Reason: This client's vital signs are within normal limits and indicate that the morphine is effective and not causing respiratory depression. A PN can assess and document the client's vital signs and pain level.

Choice C Reason: This is the correct answer because this client has acute and severe pain that may require immediate intervention and reassessment. An RN can evaluate the cause and severity of the pain, administer additional analgesics as prescribed, and implement nonpharmacological measures to relieve the pain.

Choice D Reason: This client has chronic and stable pain that is managed by a fentanyl patch. A PN can replace the patch according to the schedule and instructions provided by the RN.

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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

Naxlex Comprehensive Predictor Exams

The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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