A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
Remove the medication from the dispensing system.
Compare the client’s wristband to the medication administration record.
Document administration of the medication.
Open the medication package.
Obtain the client’s apical heart rate.
Correct Answer :
Choice B: Compare the client’s wristband to the medication administration record.
This is the first step to ensure the right patient receives the right medication. This is part of the “five rights” of medication administration.
Choice A: Remove the medication from the dispensing system. This is the second step to obtain the medication from the appropriate source and check the expiration date and dosage.
Choice C: Document administration of the medication. This is the last step to record the time, route, dose, and any adverse effects of the medication.
Choice D: Open the medication package. This should not be done before comparing the client’s wristband to the medication administration record, as it may result in giving the wrong medication or dose to the wrong patient.
Choice E: Obtain the client’s apical heart rate. This should not be done before opening the medication package, as it may delay the administration of the medication or cause confusion with other medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
To calculate the amount of heparin to administer, use the formula:
mL of heparin=units available units ordered×1mL available
Substituting the values given in the question, we get:
mL of heparin=100004000×11=0.4
Therefore, the nurse should administer 0.4 mL of heparin.
Normal ranges for heparin therapy vary depending on the condition being treated and the laboratory method used to measure APTT.
A general range is 60 to 80 seconds or 1.5 to 2.5 times the control value.
Correct Answer is A
Explanation
The nurse should instruct the client to avoid drinking beverages while sucking on a nicotine lozenge because this can interfere with the absorption of nicotine and reduce its effectiveness. Some possible explanations for the other choices are:
Choice B is wrong because chewing nicotine gum for 10 minutes before spitting it out is too short.
The recommended duration is at least 30 minutes to allow enough nicotine to be released and absorbed through the lining of the mouth.
Choice C is wrong because changing the nicotine patch every other day is not frequent enough.
The patch should be changed daily and applied to a different skin site to prevent irritation and ensure a steady dose of nicotine.
Choice D is wrong because administering 2 sprays of nicotine nasal spray in each nostril with each dose is too much.
The recommended dose is one spray per nostril, up to five times per hour or 40 times per day.
Using too much nasal spray can cause side effects such as nasal irritation, sneezing, coughing, headache, or nausea.
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