A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Request a medication reconciliation form from the pharmacy.

Ask the client if she received the 1700 medication.

Contact the previous nurse to determine if the client received the medication.

Administer the medication and document the current time.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.

Choice B Reason:

Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.

Choice C Reason:

Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.

It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.

Choice D Reason:

Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason:

Avoid entering the client's room unless requested during the night is inappropriate. While minimizing entries can reduce disruptions, it's important for the nurse to perform necessary checks and care interventions. Avoiding the room completely might compromise the client's safety or care.

Choice B Reason:

Turn off alarms on bedside monitoring equipment is inappropriate. Disabling alarms can jeopardize patient safety as these alarms often indicate critical changes in the client's condition. Adjusting alarm settings or investigating if noise levels can be reduced without compromising safety would be more appropriate.

Choice C Reason:

Conduct staff communications away from the client's room is appropriate. This intervention helps minimize noise levels near the client's room, creating a quieter environment conducive to sleep. Staff conducting communications away from the room reduces unnecessary disturbances that might affect the client's rest.

Choice D Reason:

Turn on the client's TV to distract from hallway noise is inappropriate. Introducing more noise, such as from a TV, might not effectively address the issue of sleep disturbance due to external noise. Additionally, it's essential to respect the client's preferences, and some may prefer a quiet environment for sleep rather than additional noise from a TV.

A. Open the innermost lower flap of the sterile kit while standing away from the sterile field. B. Open each side flap of the sterile kit individually while pulling to the side. C. Open the outside cover of the sterile kit and remove the dust cover. D. Grasp the outermost flap of the sterile kit while opening away from the body. E. Prepare a dry work surface above the waist level.

Correct Answer is E,C,D,B,A

Explanation

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is reviewing a client's medication administration record at 1930. The nurse notes that the documentation for the 1700 regular insulin dose is missing. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

Correct Answer is C

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Correct Answer is E,C,D,B,A

Explanation

A nurse is assisting with the care of a client who has a closed chest tube drainage system. Which of the following actions should the nurse take?

A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is reinforcing discharge instructions with a client who is walking with crutches. Which of the following statements by the client indicates an understanding of the instructions?

A nurse is caring for a client who is angry and states, "The doctor gave me the wrong information. I was lied to!" Which of the following responses by the nurse is appropriate?

A nurse is collecting a capillary blood sample from an older adult client. After puncturing the client's finger, the nurse is unable to obtain an adequate amount of blood. Which of the following actions should the nurse take?

A nurse is performing postmortem care for a client who was a devout Muslim. Which of the following actions should the nurse take?

A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

A nurse is caring for a who speaks a different language than the nurse and is 6 hr postoperative. Which of the following actions should the worse take to determine the client's level of pain?