A male client tells the practical nurse (PN) that he usually takes a smaller white tablet, not the large blue tablet that the PN gives him. Which action should the-PN implement first?
Check the medical record to verify the medication's name and strength.
Reassure the client that the blue tablet is the correct medication.
Explain that the tablets are from different manufacturers
Withhold the medication and notify the healthcare provider.
The Correct Answer is A
A. Check the medical record to verify the medication's name and strength: The first action is to verify the medication against the medical record to ensure it is the correct drug, dose, and formulation. This prioritizes patient safety by confirming accuracy before administration, preventing possible medication errors.
B. Reassure the client that the blue tablet is the correct medication: Reassuring the client without verifying the medication could risk administering the wrong drug. Even if the nurse believes the medication is correct, professional standards require verification when a discrepancy is noted by the patient.
C. Explain that the tablets are from different manufacturers: Differences in tablet appearance between manufacturers are common, but assuming this without verifying could result in a serious medication error. Visual differences should always be validated against the order and pharmacy records first.
D. Withhold the medication and notify the healthcare provider: Withholding the medication and notifying the healthcare provider may be appropriate if verification reveals a problem. However, the first step is to check the medical record to determine if the medication given matches the prescribed drug and dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.
Correct Answer is B
Explanation
A. Limit ROM assessment to the lower extremities only: Focusing only on the lower extremities does not fully address the concern. Any physical exertion could further strain the respiratory system when the client is already tachypneic and in distress.
B. Defer ROM assessment because of the respiratory rate: A respiratory rate of 30 breaths per minute indicates respiratory distress. Physical exertion, even mild, could worsen oxygenation issues. Protecting respiratory function is the priority, so the ROM assessment should be deferred until the client's condition stabilizes.
C. Ask client to perform flexion and extension of arms 5 times: Even minimal arm movements could increase oxygen demand and fatigue in a client already experiencing respiratory compromise, making this unsafe at the moment.
D. Observe the client performing lateral flexion of the waist: Lateral flexion involves significant muscular effort and could further tax respiratory function. It is not appropriate when the client is tachypneic and needs respiratory support.
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