A nurse administered ketorolac 30 mg IM to a client who is postoperative.
Which of the following information should the nurse document? (Select all that apply)
Gauge and length of needle.
Medication expiration date.
Dose of medication administered.
Site of injection.
Time of administration.
Correct Answer : A,C,D,E
Choice A rationale:
The gauge and length of needle used for an IM injection are important to document. This information can help track which supplies were used and can be useful for future reference.
Choice B rationale:
While it’s important to check the medication expiration date before administration, it’s not typically documented after administering medication.
Choice C rationale:
The dose of medication administered should always be documented. This helps ensure accurate medical records and allows healthcare providers to track how much of a medication a patient has received.
Choice D rationale:
The site of injection should be documented. This can help prevent complications such as repeated use of the same injection site.
Choice E rationale:
The time of administration should be documented. This helps keep track of when the patient received their medication, which is crucial for medications that need to be given at specific intervals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.
Choice B rationale:
Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.
Choice C rationale:
A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.
Choice D rationale:
A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.
Correct Answer is A
Explanation
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
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