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.

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 ["12"]

Explanation

1. Convert the child's weight from pounds to kilograms:

There are approximately 2.2 pounds in 1 kilogram.

33 pounds / 2.2 pounds/kg = 15 kg (approximately)

2. Calculate the total milligrams of amoxicillin needed per dose:

The order is for 20 mg/kg/dose.

The child weighs 15 kg.

20 mg/kg * 15 kg = 300 mg

3. Determine the concentration of the amoxicillin suspension:

The label shows the concentration is 125 mg/5 mL.

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

125 mg / 5 mL = 300 mg / x mL

5. Solve for x:

Cross-multiply: 125x = 300 * 5

125x = 1500

x = 1500 / 125

x = 12 mL

Answer: You will administer 12 mL per dose.

A. The mother should not take any medication while breast feeding in order to prevent harm to the infant B. Many medications cross into the breast milk in small amounts and could cause harm to the infant C. While medication can cross into the breast milk, no infants have ever been harmed because of this D. It is unlikely that a large enough amount of medication will cross into the breast milk and cause harm to the infant.

Correct Answer is B

Explanation

A) The mother should not take any medication while breast feeding in order to prevent harm to the infant: This statement is too restrictive and not accurate. While some medications should be avoided during breastfeeding, many medications can be taken safely in small amounts. The focus should be on which medications are safe for breastfeeding, not a blanket prohibition on all medications. Some medications are compatible with breastfeeding, and the benefits of taking them may outweigh any potential risks.

B) Many medications cross into the breast milk in small amounts and could cause harm to the infant: This statement is correct. While many medications do pass into breast milk in small amounts, it’s important to recognize that some medications can pose risks to the infant depending on the type of medication, dosage, and timing of breastfeeding. Nurses should educate the mother to always consult with a healthcare provider before taking any medication while breastfeeding.

C) While medication can cross into the breast milk, no infants have ever been harmed because of this: This statement is not accurate. While many medications may pass into breast milk in small amounts, there are documented cases of infants being harmed by medications transferred via breastfeeding. It is crucial to be cautious and informed about the safety of medications taken during breastfeeding.

D) It is unlikely that a large enough amount of medication will cross into the breast milk and cause harm to the infant: While it may be true that in many cases, only small amounts of medication pass into breast milk, this statement oversimplifies the issue. The amount and type of medication, as well as the infant’s age, weight, and health, are all factors that need to be considered. Some medications may pose a significant risk to the infant, and careful evaluation is necessary.

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

Laboratory Test	Result	Normal Range
Sodium	146 mEq/dL	135-145 mEq/L
Calcium	8.2 mg/dL	8.4-10.2 mg/dL
Magnesium	1.2 mg/dL	1.6-2.2 mg/dL
Gastric pH	6	1-4

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

The order reads "amoxicillin 20mg/kg/dose PO every 8 hours." The child weighs 33 pounds. Using the label below, how many mL will you administer per dose? (Enter a number only, answer to the nearest tenths place)

Correct Answer is ["12"]

Explanation

The nurse is providing discharge instructions to a female client who delivered a healthy, full-term infant. What information should the nurse provide about taking medications while breast feeding?

Correct Answer is B

Explanation

Which medications are most likely to be used in a dual drug therapy program for peptic ulcer disease from H. pylori?

During a period of time when the computerized medication order system was down, the prescriber wrote admission the nurse is transcribing them. The nurse is having difficulty transcribing one order because of the prescriber's handwriting. Which is the best action for the nurse to take at this time?

The nurse has identified several diagnoses for a client in the hospital. Which problems should the nurse identify as having highest priority?

The client is to receive acetaminophen 1000 mg IV Q6 hours. Today, the nurse administered acetaminophen 1000 mg PO. Which of the 9 rights was not followed in this situation?

When given a scheduled morning medication, the client states, "I haven't seen that pill before. Are you sure it's correct?" The nurse checks the medication administration record and verifies that it is listed. Which is the nurse's best response?

The nurse is caring for client with liver failure admitted with hepatic encephalopathy, Lactulose is ordered Q2 hours. What assessment finding should the nurse use to best evaluate therapeutic response of the medication?

The healthcare provider has ordered 5 mg morphine intravenously for pain control. At home, the client takes 30mg of morphine sulfate by mouth twice daily. The client asks the nurse why they are receiving such a small dose. What is the best response by the nurse?