A nurse is planning to administer a medication to a client. What action should the nurse plan to take to ensure the medication is given for the right indication?
Verity calculations with another nurse.
Check the label against the order.
Review the client's medical history.
Confirm the name on the prescription.
The Correct Answer is C
Rationale:
A. Verifying calculations with another nurse is an important safety step to ensure the correct dose is administered, especially for high-risk medications. However, this action focuses on dosage accuracy rather than whether the medication is appropriate for the client’s medical condition or therapeutic need. Correct calculation alone does not guarantee that the medication is indicated for the client’s current diagnosis.
B. Checking the label against the order ensures the nurse selects the right medication and dose and matches it to the prescription. This step is critical to prevent administration errors, but it does not provide information about whether the medication is indicated for the client’s condition or whether it is safe considering their medical history or concurrent medications.
C. Reviewing the client’s medical history is the most important action to ensure the medication is given for the right indication. By examining the client’s diagnoses, current symptoms, comorbidities, allergies, and other medications, the nurse can confirm that the prescribed medication is appropriate for the client’s needs. This step helps prevent giving a medication that is unnecessary, contraindicated, or potentially harmful. For example, administering a beta-blocker to a client with bradycardia or giving an NSAID to a client with renal impairment could cause serious complications if the indication and client history are not considered.
D. Confirming the name on the prescription ensures the right client receives the medication, which is essential for safety, but it does not verify that the medication is appropriate for the client’s health condition. Administering the correct drug to the wrong client or the correct drug to a client without proper indication can both result in adverse outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Peripheral neuropathy is a chronic condition often related to diabetes or nerve damage. While it may be associated with hypoxia in some cases, it is not an acute or immediate indicator of oxygen deprivation.
B. Pursed-lip breathing is a compensatory mechanism used by clients with respiratory distress or chronic lung disease to improve ventilation. It indicates the body is attempting to manage hypoxia but is not an emergency sign on its own.
C. Delayed capillary refill suggests poor peripheral perfusion, which can be concerning, but it reflects a localized or early sign of compromised circulation rather than severe hypoxia.
D. Central cyanosis is the most concerning finding. It indicates that oxygen saturation in the arterial blood is critically low, affecting vital organs. The presence of blue discoloration in the lips, tongue, or mucous membranes reflects significant hypoxemia and requires immediate assessment and intervention, such as oxygen therapy and evaluation of the underlying cause.
Correct Answer is A
Explanation
Rationale:
A. Dipping the reagent strip into fresh urine is the correct step when performing a bedside urinalysis. The nurse should collect a fresh urine sample, briefly immerse the reagent strip so all test pads are moistened, remove it immediately, and then compare the color changes to the manufacturer’s chart at the specified times. This ensures accurate results for substances such as glucose, protein, ketones, blood, and leukocytes.
B. Touching the reagent strip in the colored areas is incorrect. The nurse should avoid touching the test pads because oils or contaminants from the hands can alter the results and lead to inaccurate readings.
C. Leaving the reagent strip in the urine for 2 minutes is incorrect. The strip should only be dipped briefly and removed immediately. Prolonged immersion can cause reagent leaching and inaccurate results. Timing for reading results occurs after removal from the urine, according to the manufacturer’s instructions.
D. Sending the reagent strip to the laboratory is unnecessary. A bedside urinalysis using reagent strips is performed and interpreted at the point of care. Only the urine specimen itself would be sent to the lab if further testing is required.
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