A nurse is assisting with the admission of a client to the medical unit. The client's valuables include a container of ginkgo biloba: The client states he takes a dose each day to improve his memory. Which of the following statements should the nurse make?
“I will check with your doctor to be sure it's okay for you to take it while you're in the hospital.”
“Are you aware of that ginkgo biloba has many adverse effects?”
“We don't allow clients to bring their own medications to the hospital with them.”
“How do you know that this ginkgo biloba improves your memory?”
The Correct Answer is A
A. “I will check with your doctor to be sure it's okay for you to take it while you're in the hospital.”: The nurse's priority is patient safety and collaborative care. Many herbal supplements, including ginkgo biloba, can interact negatively with prescription medications (e.g., increasing the risk of bleeding when taken with anticoagulants). The supplement must be verified by the physician and included in the medication reconciliation before use in the hospital setting. This response is professional, respectful of the client's choice, and ensures safety.
B. “Are you aware of that ginkgo biloba has many adverse effects?”: This response uses closed-ended questioning, is confrontational, and may make the client feel defensive or judged. While adverse effects are important, a non-therapeutic approach should be avoided.
C. “We don't allow clients to bring their own medications to the hospital with them.”: While clients are typically not allowed to self-administer their home medications, the facility should reconcile, store, and often administer the client's home medications (including supplements), if approved by the provider, to ensure consistency of care.
D. “How do you know that this ginkgo biloba improves your memory?”: This question is challenging the client's belief and is dismissive of their personal health practices. While exploring patient knowledge is important, this framing is judgmental and focuses on debating the efficacy rather than ensuring safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The anterior thigh:The anterior (front) aspect of the thigh is the location of the rectus femorismuscle. While this can be used for injections, it is distinct from the vastus lateralis.
B. The upper arm: The upper arm is the location of the deltoidmuscle, a common site for small-volume vaccines.
C. The side of the thigh:The vastus lateralis is located on the lateral (outer/side) aspect of the thigh. It is a preferred site for Intramuscular (IM) injections, especially in infants and children, because it is a large muscle mass generally free of major nerves and blood vessels.
D. The back of the hip:This describes the dorsogluteal site. This site is no longer recommended for injections due to the high risk of striking the sciatic nerve or injecting into superior gluteal artery.
Correct Answer is C
Explanation
A. Insulin 100 unit:A 100-unit insulin syringe holds up to 100 units (1 mL). While it can technically hold 15 units, it is calibrated in 2-unit increments and is not the most precise option for small doses like 15 units.
B. 1-ML:A 1-mL syringe (often a Tuberculin or TB syringe) is calibrated in milliliters (mL) and hundredths of a milliliter (0.01 mL). Since the order is in units, a TB syringe is only appropriate if a conversion table is used, which is highly discouraged and error-prone for insulin administration.
C. Insulin 50 unit:A 50-unit insulin syringe holds up to 50 units (0.5 mL) and is calibrated in 1-unit increments. It provides the highest level of accuracy for measuring small insulin doses, such as the ordered 15 units, making it the preferred choice over a 100-unit syringe.
D. 3mL:A 3-mL syringe is far too large and is calibrated in milliliters (0.1 mL increments). It cannot accurately measure a dose as small as 15 units of insulin.
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