A nurse is caring for a client.
Exhibits

The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?

Propranolol

Pantoprazole

Lovastatin

Morphine

Answer and Explanation

The Correct Answer is A

A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.

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Correct Answer is C

Explanation

A. Labeling the feeding bag is important for ensuring the safety and monitoring of feeding times, but it is not the first action.
B. Hanging the feeding bag at the correct height ensures proper flow of the feeding but is not the first action.
C. Aspirating the client's stomach contents is the first action to check for residuals and ensure the placement of the NG tube is correct, preventing aspiration.
D. Warming the feeding to room temperature is important for client comfort but is not the first action.

A. Return the excess medication to the secure cabinet. B. Save the excess medication for the next administration. C. Place the excess medication in the sharps container. D. Have a second nurse witness the disposal of the excess medication.

Correct Answer is D

Explanation

A. Returning the excess medication to the secure cabinet is not appropriate as it can lead to contamination and safety issues.
B. Saving the excess medication for the next administration is not safe practice due to potential contamination.
C. Placing the excess medication in the sharps container is not the correct procedure for disposing of controlled substances.
D. Having a second nurse witness the disposal of the excess medication ensures proper documentation and accountability for controlled substances.

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A nurse is caring for a client. Exhibits The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?

Nursing Test Bank

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A nurse is caring for a client.
Exhibits

The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?