A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Documents medication administration prior to administering it.

Verifies the medication against the prescription and medication label.

Checks the provider's orders and confirmed dosage in a medication reference guide.

Scans the bar code on the medication administration record and the client's arm band

Answer and Explanation

The Correct Answer is A

A. Documents medication administration prior to administering it: Documenting medication administration before actually administering it is incorrect and can lead to errors in documentation. The nurse should document medication administration after ensuring the medication is given to the client.

B. Verifies the medication against the prescription and medication label: This is a correct action. The nurse should verify the medication against the prescription and medication label to ensure accuracy before administering it.

C. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct action. The nurse should check the provider's orders and confirm the dosage in a reliable medication reference guide to ensure accuracy before administering the medication.

D. Scans the barcode on the medication administration record and the client's armband: This is a correct action. Scanning the barcode on the medication administration record and the client's armband helps ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.

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Correct Answer is D

Explanation

A. Hold the injection if seizure activity is present:

This is incorrect. Phenytoin is an antiepileptic medication used to prevent seizures. If a client with a seizure disorder is experiencing seizure activity, it is essential to administer phenytoin promptly to help control and prevent further seizures.

B. Administer the medication at 100 mg/min:

This is incorrect. Phenytoin should be administered at a rate no faster than 50 mg/min to reduce the risk of adverse effects such as hypotension, arrhythmias, and cardiovascular collapse. Rapid infusion can cause adverse reactions such as hypotension, bradycardia, and cardiac arrhythmias.

C. Dilute the medication with dextrose 5% in water:

This is incorrect. Phenytoin should not be diluted with dextrose-containing solutions, as it can cause precipitation and result in clogging of the IV line. It is typically administered undiluted or diluted with normal saline solution.

D. Administer a saline solution after injection:

This is the correct action. After administering phenytoin IV, it is recommended to flush the IV line with normal saline solution to ensure that the medication is fully delivered and to prevent any remaining medication from precipitating in the IV line, which could lead to occlusion.

A. "Gradually decrease the dose once tolerance to the effect is reached." B. "Take most of the daily dose at bedtime." C. "Take the medication with meals." D. "Distribute the doses evenly throughout the day."

Correct Answer is B

Explanation

A. "Gradually decrease the dose once tolerance to the effect is reached." - Gradually decreasing the dose may help mitigate daytime sedation, but it's not the most appropriate initial response. Additionally, it should be done under the guidance of a healthcare provider.

B. "Take most of the daily dose at bedtime." - This response is appropriate because diphenhydramine commonly causes drowsiness, and taking most of the dose at bedtime can help minimize daytime sedation.

C. "Take the medication with meals." - Taking diphenhydramine with meals may reduce the risk of gastrointestinal upset but is unlikely to significantly decrease daytime sedation.

D. "Distribute the doses evenly throughout the day." - This approach may not effectively minimize daytime sedation because diphenhydramine's sedative effects are prolonged and may persist throughout the day if taken at regular intervals. Taking most of the dose at bedtime is a more practical strategy.

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A charge nurse is observing a newly licensed nurse administer medications to a client. Which of the following actions by the newly licensed nurse should prompt the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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