A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

"Morphine 3.0 mg sub q every 4 hr PRN for pain."

"Morphine 3 mg subcutaneous every 4 hr PRN for pain."

"Morphine 3 mg SC q 4 hr PRN for pain."

"Morphine 3 mg SQ every 4 hr PRN for pain."

Answer and Explanation

The Correct Answer is B

A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." Including a trailing zero (3.0 mg) is considered unsafe and is discouraged in medication documentation. It increases the risk of a tenfold overdose if the decimal is missed.
B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." This entry uses the correct dosage format without a trailing zero, the full term "subcutaneous" instead of abbreviations, and proper medical terminology. It adheres to safe documentation practices as per The Joint Commission guidelines.
C. "Morphine 3 mg SC q 4 hr PRN for pain." The abbreviation “SC” is considered unsafe and prone to misinterpretation. Also, "q" for "every" is discouraged in clinical documentation due to potential misreading and error.
D. "Morphine 3 mg SQ every 4 hr PRN for pain." The abbreviation “SQ” can be misinterpreted or mistaken for “5 every” or other terms. Safe practice requires spelling out “subcutaneous” to prevent errors in medication administration.

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Correct Answer is C

Explanation

A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.

A. Ensure the formula cold before administration B. Check placement of the feeding tube by x-ray unce daily. C. Maintain the head of the clients bad at a 20 angle or higher. D. Check gastric residuas every 4 hr. E. Change the hooping container and tubing every 24

Correct Answer is ["D","E"]

Explanation

A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.

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A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply)

Correct Answer is ["D","E"]

Explanation

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