A nurse is reviewing a healthcare provider's prescription that reads "acetaminophen 650 mg PO." What is the nurse's best action?

Hold the medication and document in the medication administration record.

Verify the client's allergies at the bedside.

Administer 650 mg of acetaminophen PO now.

Call the healthcare provider for clarification of the prescription.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Holding the medication and documenting it in the medication administration record is not appropriate unless there is a specific concern, such as an allergy or contraindication. Automatically holding a standard dose without reason could delay necessary treatment.

B. Verifying the client’s allergies at the bedside is the best action. Before administering any medication, the nurse must ensure that the client is not allergic to the drug, in this case acetaminophen. This is a critical safety check that helps prevent potentially severe allergic reactions, such as rash, hives, or anaphylaxis. Checking allergies is a standard part of the “rights of medication administration.”

C. Administering 650 mg of acetaminophen immediately would be premature without first confirming that the client has no known allergy or contraindication. Even though the dose is within standard limits, safety checks must be completed before administration.

D. Calling the healthcare provider for clarification is unnecessary here because the prescription is clear: the drug (acetaminophen), dose (650 mg), and route (PO) are all specified. No ambiguity exists in the order that requires clarification.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. "I will alternate cheeks with each dose to avoid irritation" indicates effective learning. Buccal medications are placed between the cheek and gum to allow absorption through the mucous membrane. Alternating cheeks with each dose helps prevent local irritation and promotes even absorption.

B. "I should chew the medication before placing it in my cheek" is incorrect. Buccal medications are meant to dissolve slowly in the mouth without chewing. Chewing can destroy the medication’s intended delivery mechanism and reduce effectiveness.

C. "I need to swallow the medication immediately after taking it" is incorrect. Buccal medications are designed to be absorbed through the oral mucosa and should not be swallowed immediately, as swallowing may reduce the medication’s efficacy.

D. "I should place the medication under my tongue to dissolve" is incorrect. Placing the medication under the tongue is the administration method for sublingual medications, not buccal medications. Buccal medications are specifically placed between the cheek and gum.

A. Place the client on 2 liters of oxygen using a nasal cannula. B. Perform a respiratory assessment and obtain vital signs. C. Ensure the nasal cannula is positioned securely in the nares. D. Observe for changes in level of consciousness or behavior.

Correct Answer is B

Explanation

Rationale:
A. Placing the client on oxygen using a nasal cannula is part of the administration process, but it should not be done before completing a baseline assessment. Starting oxygen without assessing the client could mask changes in respiratory status or lead to inappropriate therapy.

B. Performing a respiratory assessment and obtaining vital signs is the correct next action. A baseline assessment—including respiratory rate, oxygen saturation, lung sounds, work of breathing, and overall vital signs—allows the nurse to evaluate the client’s current oxygenation status and determine the appropriate oxygen delivery method and flow rate. This step also provides a reference point for monitoring the effectiveness and safety of therapy.

C. Ensuring the nasal cannula is positioned securely is important but occurs after determining the correct flow rate and delivery method based on the assessment and order. Proper placement alone does not ensure safe or effective oxygen therapy.

D. Observing for changes in level of consciousness or behavior is part of ongoing monitoring but is not the first action. Baseline assessment must be completed first to identify deviations from the client’s usual status and guide safe oxygen administration

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A nurse is reviewing a healthcare provider's prescription that reads "acetaminophen 650 mg PO." What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse provides education to a client on buccal medication. Which statement by the client indicates effective learning?

Correct Answer is A

Explanation

A nurse plans care for a client with a new order for oxygen. After verifying the healthcare provider's order for oxygen therapy, what action should the nurse plan to take next?

Correct Answer is B

Explanation

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