A nurse is preparing to administer heparin to a client. The nurse notices that the client's medical record indicates that the client has already been receiving anticoagulation therapy at home. Which of the following actions should the nurse take?

Administer the medication as prescribed.

Inform the client of her right to refuse any treatment.

Contact the Occupational, Health, and Safety Administration (OSHA).

Clarify the prescription with the provider.

Answer and Explanation

The Correct Answer is D

A. Administering heparin without clarifying the client's existing anticoagulation therapy could lead to potential overdosing or adverse effects due to cumulative anticoagulant effects.
B. While informing the client of her right to refuse treatment is important, it does not address the potential risk of duplicative therapy in this situation.
C. Contacting OSHA is not relevant to the situation of clarifying medication orders.
D. Clarifying the prescription with the provider is essential to ensure the safety and appropriateness of administering heparin in the context of the client's existing therapy, preventing medication errors and ensuring optimal patient care.

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Correct Answer is B

Explanation

A. Bringing the dropper from below the client's eye is incorrect as it increases the risk of contamination from the eyelashes.
B. Holding the ophthalmic solution 1 to 2 cm (1/2 to 3/4 in) above the lower conjunctival sac allows for accurate instillation into the eye without touching the dropper tip to the eye or eyelashes.
C. Instilling drops into the inner canthus is incorrect; drops should be placed into the conjunctival sac to ensure proper absorption.
D. Asking the client to look down may help expose the lower conjunctival sac but is not the correct action for administering the drops.

A. At the time of documentation B. In the area where the nurse obtained the medication C. In the nurses' station while reviewing the provider's prescription D. At the client's bedside before administration

Correct Answer is D

Explanation

A. Performing the final medication check at the time of documentation may result in errors if there are discrepancies between the prescription and what is documented.
B. Checking the medication in the area where it was obtained may not ensure accuracy regarding patient identity, dose, or route before administration.
C. Reviewing the provider's prescription at the nurses' station is important but should not replace the final bedside check immediately before administration.
D. Performing the final medication check at the client's bedside ensures accuracy and patient safety by verifying the correct medication, dose, route, and patient identity directly before administration.

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A nurse is preparing to administer heparin to a client. The nurse notices that the client's medical record indicates that the client has already been receiving anticoagulation therapy at home. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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