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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A Reason:
Inflating the catheter's balloon is inappropriate. Inflating the balloon at this point is not recommended. The balloon should only be inflated once the catheter is in the bladder and urine starts to flow.
Choice B Reason:
Twisting the catheter gently is appropriate. Twisting the catheter gently may help navigate any obstruction or resistance within the urethra. However, it is crucial to be cautious and not force the catheter. If resistance persists or if the catheter cannot be advanced further, the nurse should reassess the situation and consider alternative actions, such as selecting a smaller catheter or seeking assistance from a more experienced healthcare provider.
Choice C Reason:
Applying lidocaine gel to the urethra is inappropriate. Applying lidocaine gel may be appropriate for lubrication and to minimize discomfort during catheter insertion, but it will not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is inappropriate. Adjusting the angle of the penis is not likely to resolve the issue of resistance. Twisting the catheter gently or reassessing the situation would be more appropriate.
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