A nurse recognizes they administered a medication over one hour when the order dictated the medication be given over 90 minutes. Which should be the first action performed by the nurse?

Prepare and administer the prescribed antidote.

Notify the charge nurse, the nurse manager, and the prescriber.

Assess the identify the presence of urgent safety issues

Complete an incident report detailing the error

Answer and Explanation

The Correct Answer is C

A) Prepare and administer the prescribed antidote: Administering an antidote would only be appropriate if the medication error resulted in a harmful reaction that requires immediate reversal. Since the issue here is the timing of medication administration, it is more important to first assess the client for any immediate effects rather than administering an antidote, which might not be necessary at this stage.

B) Notify the charge nurse, the nurse manager, and the prescriber: While notifying the appropriate staff is crucial, the first action should be assessing the client for any safety concerns or complications resulting from the medication administration error. Immediate evaluation of the client's condition should take precedence over notification.

C) Assess and identify the presence of urgent safety issues: The first priority in this situation is to assess the client for any adverse effects or reactions due to the medication being administered too quickly. This could include monitoring for signs of toxicity, adverse reactions, or changes in vital signs that may indicate a potential risk to the client’s health. Once the client's status is assessed, further actions such as notifying other staff or completing an incident report can follow.

D) Complete an incident report detailing the error: While documenting the error in an incident report is necessary, this should not be the first step. The immediate priority is to ensure the client’s safety by assessing their condition, as an error in the timing of medication administration may result in unwanted side effects or complications that need to be addressed first.

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Correct Answer is C

Explanation

A) Lying flat on the back: Positioning the client flat on their back is not the most effective position for administering a rectal suppository. The correct position allows for easier insertion and proper absorption of the medication. Lying flat on the back may make it difficult for the nurse to administer the suppository in the correct manner.

B) Lying flat on the stomach: Lying flat on the stomach is not recommended for the administration of a rectal suppository, as it can be uncomfortable for the client and can impede the ability to access the rectal area. The side-lying position is more effective for both client comfort and proper placement of the suppository.

C) Left side-lying: The left side-lying position, often referred to as the Sims' position, is the most appropriate for administering a rectal suppository. This position helps to expose the rectal area, allows for easier insertion, and promotes the suppository’s absorption, as gravity can assist in its positioning within the rectum.

D) Right side-lying: The right side-lying position is not as effective as the left side-lying position for the administration of a rectal suppository. The left-side position helps to ensure the smooth placement of the suppository and promotes its absorption. Therefore, the right side is not the optimal choice.

Correct Answer is ["4"]

Explanation

1. Determine the concentration of the diphenhydramine:

The label states 12.5 mg/5 mL.

2. Set up a proportion to find the volume (in mL) needed:

12.5 mg / 5 mL = 10 mg / x mL

3. Solve for x:

Cross-multiply: 12.5x = 10 * 5

12.5x = 50

x = 50 / 12.5

x = 4 mL

Answer: The nurse should teach the parent to administer 4 mL.

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A nurse recognizes they administered a medication over one hour when the order dictated the medication be given over 90 minutes. Which should be the first action performed by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is ordered to receive a laxative by rectal suppository. How should the nurse position the client during the administration of the suppository?

Correct Answer is C

Explanation

The prescription reads for diphenhydramine 10 mg PO every 4-6 hours as needed for runny nose and allergy symptoms. Using the label below, how many mL will the nurse teach the parent to administer? Enter a numeric value only. Answer to the nearest whole mL

Correct Answer is ["4"]

Explanation

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