A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?

Nitroglycerin transdermal was applied to a client’s chest.

Cefotaxime was administered to a client after obtaining blood cultures.

Digoxin was administered to a client who has a heart rate of 64/min.

Insulin lispro was administered to a client immediately before bed.

Answer and Explanation

The Correct Answer is D

Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.

Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.

Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.

Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.

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Correct Answer is B

Explanation

This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.

Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.

Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.

Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure

condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.

Normal ranges for heart failure clients are:

Blood pressure: less than 140/90 mmHg
Heart rate: 60 to 100 beats per minute
Respiratory rate: 12 to 20 breaths per minute
Oxygen saturation: greater than 95%
Weight: stable or decreasing within 2 to 4 pounds per week

A. Blood pressure 170/82 mm Hg. B. Respiratory rate 18/min. C. Pulse rate 48/min. D. Potassium 4 mEq/L.

Correct Answer is C

Explanation

Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.

Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.

Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.

Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.

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A nurse is reinforcing teaching with a newly licensed nurse about incident reports. The nurse should identify that which of the following situations requires the completion of an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

Correct Answer is B

Explanation

A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?

Correct Answer is C

Explanation

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A nurse is reinforcing teaching with a newly licensed nurse about incident reports.
The nurse should identify that which of the following situations requires the completion of an incident report?