While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

Ask the patient why this medication has been ordered.

Verify with the hospital administration the reason for the medication.

Verify with the prescribing healthcare provider the reason for the medication.

Ask another nurse why the patient is getting this medication.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Asking the patient why this medication has been ordered is not the appropriate action because patients might not have accurate medical knowledge to provide a valid explanation for the prescription. The nurse should rely on healthcare professionals for accurate information.

Choice B rationale:

Verifying with the hospital administration is not necessary in this situation. The decision to prescribe medication is made by the healthcare provider, not the hospital administration.

Choice C rationale:

Verifying with the prescribing healthcare provider is the most appropriate action. The healthcare provider has the medical knowledge and rationale for prescribing a specific medication. This ensures that the nurse administers the medication safely and in alignment with the patient's condition and treatment plan.

Choice D rationale:

Asking another nurse might not yield accurate information about the rationale behind the medication order. It's best to directly communicate with the healthcare provider responsible for the patient's care.

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Correct Answer is B

Explanation

A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.

B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.

C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.

D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.

A. Reposition the client every 3 hours. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

Correct Answer is A

Explanation

Choice A rationale:

Repositioning the client every 3 hours is a crucial intervention to prevent skin breakdown in older adults who are immobile or have limited mobility. Prolonged pressure on certain areas can lead to ischemia and tissue damage, particularly over bony prominences. Repositioning helps to distribute pressure evenly, maintain circulation, and reduce the risk of pressure ulcers.

Choice B rationale:

Massage of bony prominences is not recommended as a preventive measure for skin breakdown. Massaging these areas can actually cause friction and shear forces, leading to further damage to the delicate skin of older adults. Gentle repositioning and maintaining proper skin hygiene are more effective strategies.

Choice C rationale:

While a diet high in protein is important for overall health, it is not a direct intervention for maintaining the integrity of the client's skin. Protein is necessary for wound healing and tissue repair, but it doesn't address the primary concern of preventing skin breakdown due to pressure.

Choice D rationale:

Applying cornstarch to keep the skin dry is not a recommended practice for preventing skin breakdown. Excessive moisture can contribute to skin breakdown, but cornstarch may not be the best solution. Proper hygiene, gentle cleansing, and appropriate use of moisture-barrier products are more effective in maintaining skin integrity.

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While preparing to administer the patient's scheduled medications, the nurse does not understand why the client will be receiving one of the prescribed drugs. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

A Medical-Surgical nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?