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. Gentamicin administered over 1 hour is an appropriate method for this medication.
B. Injecting Demerol IM into the vastus lateralis is an acceptable site for adults.
C. Crushing bupropion XL (extended-release) tablets is contraindicated as it alters the drug's release mechanism, which can lead to a risk of overdose or ineffective treatment, requiring an incident report.
D. Using a 25-gauge ⅝ inch needle for heparin injection is an appropriate technique.

A. Are you fully insured? B. Is it possible that you are pregnant? C. Do you take any medications? D. What was your last meal? E. What happened before you fell? F. Do you live with anyone?

Correct Answer is ["A","B","D","F"]

Explanation

A. Peripheral IV in large vein
Vancomycin should be administered through a large-bore IV to minimize the risk of complications such as phlebitis and to ensure effective drug delivery. This is a key factor in safely administering the medication.
B. Dosage in safe range
Confirming that the dosage is within the safe range ensures that the medication is administered at an effective but non-toxic level. Proper dosing is essential for achieving therapeutic effects without causing harm.
C. No known allergies
Ensuring that the client has no known allergies to vancomycin is critical to prevent allergic reactions. This step is necessary for the safe administration of the antibiotic.
D. Potassium 4.4 mEq/L (4.4 mmol/L)
While normal potassium levels are important for overall health, they do not specifically indicate the safety of vancomycin administration. Other factors such as IV access and dosage are more directly related to the safety of vancomycin.
E. Used for prophylaxis
Vancomycin is used for endocarditis prophylaxis in this case, which aligns with the clinical guidelines for preventing infections. Understanding the purpose of the medication supports its appropriate use in the client’s care.
F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
An elevated BUN level might indicate renal impairment, which could affect vancomycin metabolism. However, this level alone does not directly address the immediate safety of administering the antibiotic compared to other factors like IV access and dosage.

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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

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report?

Correct Answer is C

Explanation

Exhibits The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Correct Answer is ["A","B","D","F"]

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?