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?
Verifies the medication against the prescription and medication label.
Documents medication administration prior to administering it.
Scans the bar code on the medication administration record and the client's arm band.
Checks the provider's orders and confirmed dosage in a medication reference guide.
The Correct Answer is B
This question tests clinical safety protocols during medication administration. It requires identifying the breach of standard documentation policies, which mandate that medications are recorded only after they have been administered to the patient, to prevent medical errors and ensure accurate, safe clinical record-keeping.
Choice A rationale
Verifying the medication against the prescription and the label is a fundamental step in the medication administration process. This action is essential for confirming the "right medication" and "right dose" to prevent dangerous medication errors and ensure patient safety.
Choice B rationale
Documentation must never occur before the medication is physically administered to the patient. Pre-documentation is a critical safety violation that creates a false record and increases the risk of error, such as omitting the dose or administering it to the wrong patient.
Choice C rationale
Scanning the bar codes on the patient's ID band and the medication label is a standard, evidence-based technological safety check. This process is designed to reduce human error by electronically verifying that the correct medication is given to the correct patient.
Choice D rationale
Checking the provider's orders and verifying doses in a reliable drug reference guide is a core competency for safe medication administration. This action demonstrates sound clinical judgment and adherence to safety practices by ensuring the dosage is appropriate before administering it to the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This question tests understanding of the therapeutic use of lactulose in cirrhosis. It requires applying the scientific principle of ammonia clearance, as the diseased liver cannot convert toxic ammonia into urea, necessitating the use of an osmotic laxative to remove ammonia from the gut.
Choice A rationale
In cirrhosis, the liver fails to convert ammonia to urea, causing high serum levels. Lactulose acidifies the gut lumen, converting ammonia to ammonium, which is trapped and excreted in the stool, effectively lowering systemic ammonia levels and preventing hepatic encephalopathy.
Choice B rationale
Lactulose does not affect potassium levels. Potassium, with a normal range of 3.5 to 5.0 mEq/L, is typically monitored in cirrhotic patients due to diuretic use, but lactulose has no direct pharmacological mechanism that would either increase or decrease serum potassium.
Choice C rationale
Lactulose is a synthetic disaccharide and does not cause significant shifts in blood glucose. While it contains sugar, it is not absorbed into the bloodstream, meaning it does not have a systemic effect on glucose levels in patients with cirrhosis.
Choice D rationale
Bicarbonate, with a normal range of 22 to 28 mEq/L, is a base that maintains systemic pH. Lactulose does not interact with the renal or respiratory systems to regulate bicarbonate or modify the blood buffering capacity in the body of the patient.
Correct Answer is A
Explanation
This question tests the knowledge of pharmacological antidotes for anticoagulant toxicity. It requires identifying the correct reversal agent that neutralizes the specific molecular structure of heparin to stop anticoagulation and control life-threatening hemorrhage effectively in a clinical emergency.
Choice A rationale
Protamine sulfate is a positively charged protein that binds to the negatively charged heparin molecule. This interaction forms a stable, inactive complex, effectively neutralizing heparin’s anticoagulant activity and reversing the risk of bleeding in overdose cases.
Choice B rationale
Potassium chloride is a mineral supplement used to treat or prevent hypokalemia. It has no pharmacological role in the reversal of heparin-induced anticoagulation and would not stop bleeding caused by an anticoagulant overdose.
Choice C rationale
Vitamin E is a fat-soluble vitamin. While it has some mild anti-platelet effects at high doses, it does not function as an antidote to heparin and has no role in the emergency management of anticoagulant-induced excessive bleeding.
Choice D rationale
Vitamin K is the pharmacological antidote for warfarin, a vitamin K antagonist. It functions by promoting the synthesis of clotting factors in the liver and is completely ineffective at neutralizing the anticoagulant effects of intravenous heparin.
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