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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Free Nursing Study Resources

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.

Correct Answer is ["100"]

Explanation

To calculate the flow rate for an IV fluid bolus, you can use the formula: (Volume in mL * Drop factor) / Time in minutes. For a 200 mL dextrose 5% in water to be administered over 30 minutes with a drop factor of 15 gtt/mL, the calculation would be (200 * 15) / 30, which equals 100 gtt/min.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is ["100"]

Explanation

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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?