A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?
Withdraws the medication from the ampule using a subcutaneous needle
Breaks the top of the ampule using an antiseptic wipe
Disposes of the ampule by placing it in a sharp’s container
Performs 3 checks of the medication before administration
The Correct Answer is A
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Obtaining client intake and output instead of delegating the task to an assistive personnel, may or may not indicate effective time management. It depends on the specific circumstances and urgency of other tasks. Delegating appropriate tasks to assistive personnel can be a component of effective time management when done judiciously.
Choice B Reason:
Documenting medications administered throughout the shift at the end of the day, is not indicative of effective time management. Delaying documentation until the end of the day can lead to inaccuracies, omissions, and potential safety concerns. Timely documentation is essential for maintaining accurate and up-to-date records.
Choice C Reason:
Reviewing a client's medical record before performing a prescribed dressing change is correct. Effective time management involves prioritizing tasks, organizing workflow efficiently, and completing tasks in a timely manner while maintaining quality of care. Option C demonstrates effective time management because reviewing a client's medical record before performing a prescribed dressing change ensures that the nurse is prepared and has all necessary information to perform the task accurately and safely. This action indicates proactive planning and organization, which are key aspects of effective time management.
Choice D Reason:
Skipping lunch to catch up on client documentation, is not indicative of effective time management. Skipping meals can negatively impact the nurse's well-being and ability to provide safe and effective care. Effective time management involves finding a balance between completing tasks efficiently and taking breaks to maintain personal health and well-being.
Correct Answer is D
Explanation
Choice A Reason:
Raising all four side rails on the bed of a confused client can be considered a form of restraint, which should be avoided unless necessary for the safety of the patient. It may infringe on the client's autonomy and dignity.
Choice B Reason:
Electing not to care for a client who had an abortion is discriminatory and violates the principle of nonmaleficence (doing no harm). Nurses have a professional obligation to provide care to all patients regardless of their personal beliefs or circumstances.
Choice C Reason:
Withholding nutrition from a client with a do-not-resuscitate (DNR) order without clear medical indications goes against the principle of beneficence and could be considered unethical. Nutritional support is a basic aspect of care that should not be withheld unless it is medically indicated or aligns with the patient's wishes.
Choice D Reason:
A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min represents ethical practice because administering prescribed opioids to a client with a terminal illness and a respiratory rate of 8/min is appropriate and aligns with the principle of beneficence. The nurse's action aims to alleviate the client's pain and suffering, which is essential in end-of-life care.
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