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:
Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.
Choice B Reason:
Elevating the arm can help reduce swelling, but it should come after stopping the infusion.
Choice C Reason:
Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.
Choice D Reason:
Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.
Correct Answer is C
Explanation
Choice A Reason:
A nurse discovers that a client's family member has administered a PCA dose: While this is a medication administration concern, it might not always require an incident report, but it should be addressed by the healthcare team to prevent future occurrences.
Choice B Reason:
A nurse observes a client vomiting after receiving an oral pain medication: This could be a medication reaction or a side effect, and it should be documented in the client's medical record, but it may not necessarily require a separate incident report.
Choice C Reason:
A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. Incident reports are typically used to document unexpected events or situations that deviate from the standard of care, and this includes situations where errors occur that could potentially harm the patient. In this case, the IV pump delivering twice the prescribed amount of fluid is a medication error that should be reported to document the occurrence and to ensure that corrective actions are taken to prevent similar incidents in the future.
Choice D Reason:
A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: This might be a situation that requires clarification and discussion among the healthcare team, but it may not necessarily require an incident report unless there is concern about patient safety.
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