When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

Verify client's identification by scanning the barcode on the armband.

Reconcile the medication to be administered with the initial client prescription.

Remove the medication from the unit dose packaging while verifying the dose.

Scan the medication barcode to document administration on the eMAR.

Answer and Explanation

The Correct Answer is A

A. Verify client's identification by scanning the barcode on the armband is correct because verifying the client’s identity is the next step after accessing the eMAR. This ensures that the right medication is given to the right client, following the “rights” of medication administration.

B. Reconcile the medication to be administered with the initial client prescription is important but should already have been completed during the medication preparation and verification process.

C. Remove the medication from the unit dose packaging while verifying the dose is part of the preparation process but occurs after confirming the client’s identity.

D. Scan the medication barcode to document administration on the eMAR is done after verifying the client’s identity and ensuring the medication is correct. It is not the immediate next step after logging into the eMAR.

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Correct Answer is B

Explanation

A. Assess the client for signs of diminished circulation in the hands is unnecessary at this stage, as the primary concern is ensuring proper crutch fit and teaching safe use.

B. Proceed with teaching the client how to walk with the crutches is correct because a space of three finger-widths between the crutch and the axilla indicates proper crutch height. This prevents nerve damage and discomfort in the axilla.

C. Ask the client to sit down while the crutch length is adjusted is not needed since the crutches are already appropriately adjusted based on the observed spacing.

D. Confer with the physical therapist for correct crutch size is unnecessary because the nurse can confirm that the crutches are properly fitted based on standard guidelines.

A. Check skin for unusual bruising. B. Palpate mucus membranes for cracks. C. Monitor color of nailbeds. D. Assess skin folds of perineal area. E. Observe skin under the breasts.

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

Explanation

A. Check skin for unusual bruising is not directly related to the client's diaphoretic condition. While bruising may be relevant in some cases, it is not the priority in this scenario, where the focus is on managing moisture and skin integrity.

B. Palpate mucus membranes for cracks is not as relevant in this situation. Cracks in the mucus membranes could indicate dehydration or other issues, but the primary concern for a diaphoretic client is skin breakdown due to moisture.

C. Monitor color of nailbeds is important in general assessment, but it is not directly related to the client's diaphoretic condition. Nailbed color may indicate circulation issues, but it is not a primary concern for this scenario.

D. Assess skin folds of perineal area is important because moisture from perspiration can accumulate in skin folds, increasing the risk for skin breakdown or infection, especially in overweight clients.

E. Observe skin under the breasts is also critical. The skin under the breasts is prone to moisture buildup, which can lead to irritation, fungal infections, or skin breakdown in overweight clients. Regular assessment of this area is necessary to prevent complications.

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When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Correct Answer is B

Explanation

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

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

Explanation

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