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 A

Explanation

Lithium is a mood stabilizer commonly prescribed for bipolar disorder, but it has a narrow therapeutic index, meaning the difference between a therapeutic dose and a toxic dose is small. Therefore, it's crucial for the client to recognize the signs of lithium toxicity. Here's the rationale for each option:

A. "Vomiting is an indication of toxicity.": This statement is correct. Vomiting is one of the early signs of lithium toxicity and should be reported to the healthcare provider immediately.

B. "I will report any loss of appetite.": While loss of appetite can be a symptom of lithium toxicity, it is not one of the most common or specific signs. Other symptoms, such as vomiting, diarrhea, tremors, and confusion, are more indicative of lithium toxicity.

C. "I will call my provider if I experience any headaches.": Headaches are not typically associated with lithium toxicity. Symptoms such as severe diarrhea, tremors, confusion, and decreased coordination are more indicative of lithium toxicity.

D. "Increased flatulence is an indication of toxicity.": Increased flatulence is not a typical manifestation of lithium toxicity. Symptoms such as gastrointestinal upset, tremors, confusion, and changes in coordination are more common signs of toxicity.

A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse used a 25-gauge 3-inch needle to administer a heparin injection. C. A nurse injected Demerol IM into the vastus lateralis site of adult. D. A client received a crushed bupropion XL tablet mixed with applesauce.

Correct Answer is D

Explanation

A. A client received gentamicin intermittent IV bolus over 1 hr:

While gentamicin is typically administered as an intermittent IV bolus, the rate of administration over 1 hour is not necessarily inappropriate. However, the specific institutional protocol or medication administration guidelines should be followed. If the rate of administration deviates significantly from the standard protocol or manufacturer's recommendations, it may warrant further investigation but may not necessarily require an incident report.

B. A nurse used a 25-gauge 3-inch needle to administer a heparin injection:

Using a 25-gauge 3-inch needle for heparin injection is not standard practice and may not be the most appropriate needle size for subcutaneous administration. However, it does not necessarily indicate a need for an incident report unless it resulted in harm to the client. It may prompt further education or clarification regarding appropriate needle selection for subcutaneous injections.

C. A nurse injected Demerol IM into the vastus lateralis site of an adult:

While Demerol (meperidine) is typically administered intramuscularly, the choice of the vastus lateralis site for injection in an adult may not be the most common practice, but it is an acceptable site for IM injections. Unless there are specific contraindications or adverse outcomes related to the site selection, this finding may not require an incident report. However, it could prompt a review of injection site selection guidelines or further education.

D. A client received a crushed bupropion XL tablet mixed with applesauce:

This finding indicates a need for an incident report. Bupropion XL (extended-release) tablets should not be crushed or chewed, as this can lead to rapid release and absorption of the medication, potentially causing adverse effects or toxicity. Administering crushed extended-release tablets is a medication error that warrants an incident report to document the event, assess potential harm to the client, and implement corrective actions to prevent recurrence.

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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 teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

Correct Answer is D

Explanation

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