After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Notify the healthcare provider.

Document the event on the chart.

Complete an incident report.

Inform the nurse on the next shift.

Answer and Explanation

The Correct Answer is A

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

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Correct Answer is C

Explanation

Choice A: Limitations to range of motion are not directly related to the application of a heating pad. A heating pad may help reduce pain and stiffness, but it does not affect the range of motion itself.

Choice B: Muscle strength and tone are also not directly related to the application of a heating pad. A heating pad may relax tense muscles, but it does not affect the strength or tone of the muscles.

Choice C: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. A heating pad can cause burns or tissue damage if the patient has impaired sensation and cannot feel the heat or pain. The nurse should check the patient's ability to perceive temperature, pressure, and pain before applying a heating pad.

Choice D: Presence of rebound phenomenon is not relevant to the application of a heating pad. Rebound phenomenon refers to the worsening of symptoms after discontinuing a medication or treatment. A heating pad does not cause rebound phenomenon.

A. Measure temperature at regular intervals. B. Assess for flushed, warm skin regularly. C. Vary sites for temperature measurement. D. Document the client's circadian rhythms.

Correct Answer is A

Explanation

Choice A Reason: This is correct because measuring temperature at regular intervals allows the nurse to monitor fever patterns and evaluate the effectiveness of interventions.

Choice B Reason: This is incorrect because assessing for flushed, warm skin regularly is not a reliable indicator of fever. Skin temperature may vary depending on environmental factors and blood flow.

Choice C Reason: This is incorrect because varying sites for temperature measurement may result in inaccurate readings. Different sites have different normal ranges and may be affected by external factors.

Choice D Reason: This is incorrect because documenting the client's circadian rhythms is not relevant to assessing fever patterns. Circadian rhythms are natural fluctuations in body functions that occur over a 24-hour cycle.

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After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is C

Explanation

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?

Correct Answer is A

Explanation

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