A nurse received a prescription to administer a medication NOW to a client. Which action should the nurse take?
Administer the medication within 90 minutes of the provider prescribing the medication.
Administer the medication at specific times until directed by the provider.
Administer the medication at every 4-hour intervals.
Administer the medication whenever the client reports specific manifestations, such as pain.
The Correct Answer is A
Choice A reason: Administering the medication within 90 minutes of the provider prescribing it aligns with the definition of a “NOW” order. A “NOW” order is intended to be given promptly but not as urgently as a STAT order, which requires immediate administration. This timeframe ensures that the medication is given in a timely manner to address the client’s needs without unnecessary delay.
Choice B reason: Administering the medication at specific times until directed by the provider is not appropriate for a “NOW” order. This approach is more suitable for routine or scheduled medications, where the timing is predetermined and consistent. A “NOW” order requires prompt action rather than adherence to a fixed schedule.
Choice C reason: Administering the medication at every 4-hour intervals is incorrect for a “NOW” order. This frequency is typical for PRN (as needed) medications or those requiring regular dosing intervals. A “NOW” order is a one-time directive that necessitates timely administration soon after the order is given.
Choice D reason: Administering the medication whenever the client reports specific manifestations, such as pain, is characteristic of PRN orders. PRN orders are given based on the client’s symptoms and needs at the time. A “NOW” order, however, is a one-time order that should be carried out promptly, regardless of the client’s immediate symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.
Choice B Reason:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.
Choice C Reason:
Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.
Choice D Reason:
Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.
Correct Answer is A
Explanation
Choice A reason: The glossopharyngeal nerve (CN IX) is primarily responsible for the gag reflex. It provides sensory input from the pharynx and posterior third of the tongue, which triggers the gag reflex when stimulated. This nerve plays a crucial role in swallowing and the reflexive action to prevent choking.
Choice B reason: The trigeminal nerve (CN V) is responsible for facial sensation and motor functions such as biting and chewing. It does not play a direct role in the gag reflex. While it is important for other sensory and motor functions, it is not involved in the reflex being assessed here.
Choice C reason: The vagus nerve (CN X) also contributes to the gag reflex by providing motor innervation to the muscles of the pharynx and larynx. However, the primary sensory input for the gag reflex comes from the glossopharyngeal nerve (CN IX). The vagus nerve works in conjunction with CN IX to complete the reflex action.
Choice D reason: The hypoglossal nerve (CN XII) controls the movements of the tongue. It is essential for speech and swallowing but does not have a role in the gag reflex. The hypoglossal nerve’s primary function is motor control of the tongue muscles.
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