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 Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle.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:
The client needs to have someone come in to help her bathe at home is incorrect. While this indicates a need for assistance with activities of daily living, such as bathing, it does not necessarily require the involvement of a social worker. This need may be addressed by home health aides or other community resources.
Choice B Reason:
The client needs to have range-of-motion exercises to assist with ambulation is incorrect. This suggests a need for rehabilitation or physical therapy services, which would typically be addressed by a physical therapist rather than a social worker.
Choice C Reason:
The client needs to arrange financial resources to purchase equipment is correct. The need to arrange financial resources indicates potential financial concerns or barriers that a social worker can assist with. Social workers are trained to help clients access resources and support services, including assistance with financial matters.
Choice D Reason:
The client needs to have someone bring oxygen tanks and equipment to her home is incorrect. While this indicates a need for assistance with arranging for medical equipment, such as oxygen tanks, it may be more closely related to coordination with home healthcare services or medical equipment providers rather than the role of a social worker.
Correct Answer is ["A","C"]
Explanation
Choice A Reason:
Providing written information to a client regarding palliative care is correct. Advocating for the client's autonomy and right to information by providing written materials about palliative care empowers the client to make informed decisions about their care.
Choice B Reason:
Documenting a client's refusal to take a prescribed medication is incorrect. While documenting a client's refusal is important for accurate medical records, it is not an example of advocacy. Advocacy involves actively supporting the client's rights, preferences, and needs.
Choice C Reason:
Obtaining an interpreter for a client who speaks a different language than the nurse is correct. Advocating for effective communication ensures that the client can fully understand and participate in their care, regardless of language barriers. Obtaining an interpreter facilitates communication and promotes the client's right to understand and be understood.
Choice D Reason:
Initiating IV access on a client who has dementia while he is sleeping is incorrect. This scenario raises ethical concerns as it involves performing a procedure on a client who is unable to provide consent due to being asleep and having dementia. Without explicit consent or a medical emergency necessitating immediate intervention, initiating IV access in this situation may not align with client advocacy principles.
Choice E Reason:
Implementing a client's plan of care based upon nursing goals is incorrect. While implementing a client's plan of care is part of the nurse's role, it is not necessarily an example of advocacy. Advocacy involves actively promoting and safeguarding the client's rights, preferences, and well-being, which may sometimes involve advocating for modifications to the plan of care based on the client's needs and goals.
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