A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia.

The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening.

Which of the following actions should the nurse take to prevent medication errors?

Double check all dosage calculations.

nusually large or small doses.

Compare the medication label to the order.

Use at least 2 client identifiers before administering a dose.

Involve and educate clients in medication administration.

Document all medication in the electronic record as soon as it is given.

Answer and Explanation

Correct Answer : A,C,D,E,F

Choice A rationale
Double-checking all dosage calculations is a critical step in preventing medication errors. This ensures that the correct dose is administered and helps avoid potentially harmful mistakes.
Choice B rationale
The option “nusually large or small doses” seems to be a typographical error and does not provide a clear action to prevent medication errors. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to ensure that the correct medication is being administered. This step helps verify that the medication matches the provider’s prescription.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice to confirm the client’s identity and prevent administering medication to the wrong person.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert the nurse to any discrepancies or concerns.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate records and ensuring that all healthcare providers have up-to-date information about the client’s medication administration.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale
Assessing the strength of deep tendon reflexes is not the most important intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client’s reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.
Choice B rationale
This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client’s heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.
Choice C rationale
Observing the color and amount of urine is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client’s renal function and fluid balance, but these are not the priority assessments.
Choice D rationale
Comparing muscle strength bilaterally is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client’s neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

A. Active bowel sounds in the lower right quadrant. B. Contraction of the left pupil when light shines in the right eye. C. Basilar lung sounds that are diminished in the left lung. D. Capillary refill of 2 seconds in the lower right foot.

Correct Answer is C

Explanation

Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

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Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

Which assessment should the nurse document when charting by exception?

Correct Answer is C

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, “Streptomycin 1 gram/25.”. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results.Which response is best for the nurse to provide?

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?