A nurse is administering a client's morning oral medications.
Which of the following actions should the nurse take?
Verify the medication three times with the medication administration record.
Document medication administration prior to administering medication.
Administer time-critical medication 60 min before or after the scheduled time.
Identify the client by using one identifier before giving the medication.
The Correct Answer is A
a. Verify the medication three times with the medication administration record.
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Clammy skin is incorrect. DKA is more likely to cause dry or flushed skin due to dehydration and the effects of high blood sugar levels. Clammy skin is usually associated with conditions that cause excessive sweating.
Choice B Reason:
Bounding pulse is incorrect. DKA can lead to tachycardia (a rapid heart rate) as the body tries to compensate for the metabolic imbalances, but a bounding pulse is not a characteristic finding of DKA.
Choice C Reason:
Elevated blood pressure is incorrect. DKA is more likely to result in an initial decrease in blood pressure due to dehydration. Elevated blood pressure may be present in other conditions but is not a primary feature of DKA.
Choice D Reason:
Fruity breath odor is correct. Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by a buildup of ketones in the blood, which results from the body breaking down fat for energy due to a lack of insulin. Fruity breath odor, often described as smelling like acetone or nail polish remover, is a classic sign of DKA. It occurs because the presence of ketones in the blood leads to the exhalation of acetone through the breath.
Correct Answer is C
Explanation
Choice A Reason:
Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.
Choice B Reason:
Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.
Choice C Reason:
Telling the APs to stop the conversation is correct. Overhearing discussions about a client's personal information by unauthorized personnel is a breach of patient privacy and confidentiality, which is a serious violation of healthcare ethics and regulations. Therefore, the nurse should address the situation immediately by telling the assistive personnel (APs) to stop the conversation. Here's why each option is appropriate or not:
Choice D Reason:
Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.
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