A nurse in a provider's office is caring for a client.

Exhibits

What actions should the nurse take? Select all that apply.

Monitor the client for dysrhythmias.

Advise the client to restrict potassium intake.

Advise the client to take the medication before bedtime.

Check the client for orthostatic hypotension.

Advise the client to change positions slowly.

Answer and Explanation

Correct Answer : A,D,E

A.   Monitor the client for dysrhythmias- The significant decrease in potassium levels (hypokalemia) can predispose the client to cardiac dysrhythmias, so monitoring for any signs or symptoms of dysrhythmias is essential.
B.   Advise the client to restrict potassium intake- With potassium levels already low (hypokalemia), restricting potassium intake further could exacerbate the deficiency. Instead, the client may need to increase their potassium intake through dietary changes or supplementation under healthcare provider guidance.
C.   Advise the client to take the medication before bedtime- There's no medication mentioned in the scenario that requires a specific timing like before bedtime.
D.   Check the client for orthostatic hypotension- The client reports dizziness and light- headedness upon standing, which are indicative of orthostatic hypotension. Checking for orthostatic hypotension involves measuring blood pressure and heart rate in different positions (lying, sitting, and standing) to assess for postural changes.
E.   Advise the client to change positions slowly- Given the client's symptoms of dizziness and light-headedness upon standing, advising them to change positions slowly can help prevent falls or injuries associated with orthostatic hypotension.

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Correct Answer is B

Explanation

A) Have another nurse verify the medication for the secondary infusion. - While medication verification is important, disconnecting the primary IV infusion is necessary to administer the antibiotic via intermittent IV bolus.

B) Hang the secondary infusion higher than the primary IV infusion. - This allows the secondary medication to flow by gravity until the bag is empty, after which the primary infusion will resume at the pre-set rate.

C) Disconnect the primary IV infusion to connect the secondary infusion. - Disconnecting the primary IV infusion is unnecessary and could interrupt the continuous infusion therapy.

D) Flush the IV site with sterile water prior to connecting the secondary infusion. - Flushing the IV site with sterile water is incorrect because it could cause hemolysis; instead, the line should be flushed with a compatible solution, such as 0.9% sodium chloride.

A. File a report with the facility to document the incident as a near miss medication error. B. Write in the client's medical record that the nurse prevented a facility medication error. C. Inform the client that medication will not be given due to a dispensary medication error. D. Contact the client's prescribing provider to report a facility medication error.

Correct Answer is A

Explanation

A) File a report with the facility to document the incident as a near miss medication error. - Reporting the incident as a near miss allows for appropriate documentation and investigation to prevent future errors.

B) Write in the client's medical record that the nurse prevented a facility medication error. - While it's important to document the incident, it should be done through the appropriate channels rather than in the client's medical record.

C) Inform the client that medication will not be given due to a dispensary medication error. - This action may cause unnecessary alarm to the client and is not the appropriate response to the situation.

D) Contact the client's prescribing provider to report a facility medication error. - While notifying the prescribing provider may be necessary, it should be done after reporting the incident to the facility and following facility protocols.

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A nurse in a provider's office is caring for a client. Exhibits What actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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A nurse in a provider's office is caring for a client.

Exhibits

What actions should the nurse take? Select all that apply.