When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?
Explain to the client that the dosage has been changed.
Withhold the medication until the dosage can be confirmed.
Inform him that he may refuse the medication and document whether or not he takes it.
Tell him to take the medication then verify the dosage at the next healthcare team meeting.
The Correct Answer is B
Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: An adolescent with multiple contusions due to a fall that occurred 2 days ago is not a client that the charge nurse should assign to the RN, as this is a stable and low-acuity client who can be safely cared for by the PN. This is a distractor choice.
Choice B: A 75-year-old client with renal calculi who requires urine straining is not a client that the charge nurse should assign to the RN, as this is a routine and non-complex task that can be performed by the PN. This is another distractor choice.
Choice C: A 30-year-old depressed client who admits to suicide ideation is a client that the charge nurse should assign to the RN, as this is an unstable and high-risk client who requires close monitoring, assessment, and intervention by the RN. Therefore, this is the correct choice.
Choice D: A 64-year-old client who had a total hip replacement the previous day is not a client that the charge nurse should assign to the RN, as this is a postoperative and moderate-acuity client who can be managed by the PN under the supervision of the RN. This is another distractor choice.
Correct Answer is C
Explanation
Choice C is correct because pushing the undiluted Dextrose slowly through the currently infusing IV is the best way to administer the medication for a client with insulin shock. Insulin shock is a condition in which the blood glucose level drops too low due to excess insulin or insufficient food intake. This can cause symptoms such as confusion, sweating, tremors, or loss of consciousness. The nurse should administer 50% Dextrose IV as a bolus injection to raise the blood glucose level quickly and prevent brain damage.
Choice A is incorrect because asking the pharmacist to add the Dextrose to a TPN solution is not appropriate for a client with insulin shock. TPN stands for total parenteral nutrition, which is a type of intravenous feeding that provides all the nutrients needed by the body. TPN solutions contain dextrose, amino acids, lipids, vitamins, minerals, and electrolytes in specific concentrations and ratios. Adding extra dextrose to a TPN solution can alter its composition and cause complications such as hyperglycemia or fluid overload.
Choice B is incorrect because mixing the Dextrose in a 50 mL piggyback for a total volume of 100 mL is not effective for a client with insulin shock. A piggyback is a type of intravenous infusion that delivers medication through a secondary tubing attached to the primary tubing of another solution. Mixing the Dextrose in a piggyback can dilute its concentration and reduce its potency. It can also delay its delivery and onset of action.
Choice D is incorrect because diluting the Dextrose in one liter of 0.9% Normal Saline solution is not safe for a client with insulin shock. Normal Saline is a type of intravenous fluid that contains sodium chloride in isotonic concentration. Diluting the Dextrose in one liter of Normal Saline can lower its concentration and increase its volume significantly. This can cause complications such as hypoglycemia or fluid overload.
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