A client is admitted with reports of shortness of breath, dyspnea on exertion, and chest pressure. The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. Which action should the nurse take?

Give the dosage recommended in the drug handbook.

Consult pharmacist for dose clarification.

Administer the medication as prescribed.

Verify the prescribed dosage with healthcare provider.

Answer and Explanation

The Correct Answer is D

D. When encountering a medication dosage that appears unusually large or different from what is expected, the nurse should always verify the prescription with the healthcare provider before administering the medication. This step ensures patient safety and helps prevent medication errors.

A. Giving the dosage recommended in the drug handbook may not be appropriate if the prescribed dosage differs significantly from the usual or recommended dosage due to patient- specific factors or other considerations.

B. In situations where the prescribed dosage seems unusually large or different from the usual guidelines, it is essential to confirm with the healthcare provider who wrote the prescription to ensure accuracy and appropriateness for the specific patient.

C. Administering the medication as prescribed without further clarification could potentially lead to harm if the prescribed dosage is incorrect or inappropriate for the patient's condition.

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Correct Answer is D

Explanation

D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.

A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.

B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.

C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.

A. Observe the client's skin and mucous membranes. B. Palpate the client's pedal pulse volume bilaterally. C. Auscultate the bowel sounds in all four quadrants. D. Determine the elasticity of the client's skin turgor.

Correct Answer is A

Explanation

A. During nasopharyngeal suctioning, the nurse should primarily focus on observing the client's skin and mucous membranes for signs of oxygenation and perfusion. This includes assessing for cyanosis, pallor, or any other signs of inadequate oxygenation.

B. Palpating the client's pedal pulses, which are pulses in the feet, is not directly relevant to nasopharyngeal suctioning. Pedal pulses are typically assessed to evaluate peripheral vascular status and circulation in the lower extremities.

C. Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. Bowel sounds are typically assessed to evaluate gastrointestinal function and motility.

D. Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. Skin turgor is typically assessed to evaluate hydration status, with decreased skin turgor often indicating dehydration.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ: Which instruction should the nurse include?

Correct Answer is D

Explanation

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is A

Explanation

The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via masal cannula. The oxygen saturation is 89%. Which action should the nurse implement?