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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.

B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.

C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.

D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.

A. "He may need a feeding tube." B. "Tell me more about what happens at mealtime." C. "Why do you think he's not eating?" D. "I'm sure it's nothing serious and his appetite will return soon."

Correct Answer is B

Explanation

Choice A Reason:
"He may need a feeding tube" is inappropriate response. Suggesting a feeding tube without further assessment or information might be premature and could cause unnecessary concern or anxiety for the son. It's essential to explore the situation more before proposing such an intervention.

Choice B Reason:
"Tell me more about what happens at mealtime” is appropriate response. This response encourages the son to provide further details about the situation, allowing the nurse to gather more information about the specific issues or challenges related to the client's eating habits. Understanding the circumstances around mealtime can help the nurse identify potential reasons for the lack of appetite or eating difficulties and offer more targeted guidance or solutions.

Choice C Reason:
"Why do you think he's not eating?" This response is inappropriate. While asking about the son's thoughts is valuable, this question might not directly address the situation at hand or provide immediate assistance or guidance to address the client's eating difficulties.

Choice D Reason:
"I'm sure it's nothing serious and his appetite will return soon” is inappropriate response. Offering reassurance without understanding the underlying cause may downplay a potentially concerning issue. It's crucial to investigate the reasons behind the lack of appetite before assuming it will resolve without further action.

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 is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

A home health nurse is reinforcing teaching about dietary needs with the son of a client. The son states, "I don't know what to do because he's not eating." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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 teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations nurse disclose health information without the client's written consent?

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 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?

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 client who is pulling on his NG tube. Which of the following actions should the nurse take first?

A nurse is caring for a client who has acute lymphocytic leukemia. The client is refusing blood products. Which one of the following responses should the nurse take?

A nurse is reinforcing teaching with a client who has an ostomy. Which of the following statements by the client indicates an understanding of the teaching?