A nurse identifies that a medication is ordered for the client as twice the regular dosage. What action should the nurse take?
Administer the medication as ordered.
Administer the standard dose and notify the prescriber.
Check to see if previous nurse gave the medication as ordered.
Collaborate with the prescriber regarding the ordered dose.
The Correct Answer is D
Collaborate with the prescriber about the order. This is because the nurse has a responsibility to ensure the safety and effectiveness of the medication administration and to question any orders that seem inappropriate or unclear. The nurse should not administer the medication as ordered without verifying it first, as this could cause harm to the client or result in a medication error. The nurse should not check to see if previous shift nurses gave the medication, as this does not address the issue of the current order and could lead to missed or duplicated doses. The nurse should not administer only the standard dose of the medication, as this could be against the prescriber’s intention and could compromise the client’s treatment or outcome.
Choice A is wrong because it does not follow the principle of safe medication administration and could put the client at risk of adverse effects or overdose.
Choice B is wrong because it does not respect the prescriber’s authority and could result in underdosing or ineffective therapy for the client.
Choice C is wrong because it does not solve the problem of the current order and could cause confusion or inconsistency in the medication administration.
Choice D is correct because it demonstrates critical thinking and professional accountability, and ensures that the order is appropriate and accurate for the client’s condition and needs.
The normal ranges for medication dosages depend on various factors, such as the type of medication, the route of administration, the client’s age, weight, renal function, liver function, and other comorbidities.
The nurse should always consult reliable sources of information, such as drug guides, pharmacists, or prescribers, to determine the safe and effective dosages for each client
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
One drop left eye daily.
This is because it uses the correct abbreviation for left eye (os) and the correct frequency (daily).
The other choices are wrong because:
Choice A uses od which means right eye, not once daily.
Choice B uses ou which means both eyes, not each eye.
Choice C uses right ear which is not an eye drop medication. Some common eye drop prescription abbreviations are:
- gt or gtt for drop or drops
- od for right eye
- os for left eye
- ou for both eyes
- bid for twice a day
- tid for three times a day
- qid for four times a day
- prn for as needed
Correct Answer is D
Explanation
Ineffective Airway Clearance. This is because a client with a Glasgow Coma Scale (GCS) of 6 has a severe impairment of consciousness and is at risk of aspiration, respiratory failure, and infection. The GCS is a clinical scale that measures a person’s level of consciousness after a brain injury based on their eye, verbal and motor responses. A GCS score of 6 indicates that the client only opens eyes to pain, makes incomprehensible sounds and shows abnormal flexion to pain.
Choice A is wrong because Acute Confusion is not a priority nursing diagnosis for a client with a GCS of 6.
Acute Confusion is a state of disorientation and impaired memory that can be caused by various factors such as medication, infection, electrolyte imbalance or dementia.
A client with a GCS of 6 is not likely to be confused, but rather unresponsive or minimally responsive.
Choice B is wrong because Self-Care Deficit is not a priority nursing diagnosis for a client with a GCS of 6.
Self-care deficit is the impaired ability to perform activities of daily living such as bathing, dressing, feeding or toileting.
A client with a GCS of 6 will need assistance with all these activities, but the most urgent concern is their airway patency and oxygenation.
Choice C is wrong because Risk for Impaired Skin Integrity is not a priority nursing diagnosis for a client with a GCS of 6.
Risk for Impaired Skin Integrity is the potential for damage to the skin or underlying tissues due to pressure, friction, shear or moisture.
A client with a GCS of 6 may be at risk for developing pressure ulcers or skin breakdown due to immobility and reduced sensation, but this is not as life-threatening as ineffective airway clearance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.