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

Notify the healthcare provider (HCP).

Document the event in the electronic health record (EHR).

Inform the nurse on the next shift.

Complete an incident report.

Answer and Explanation

The Correct Answer is A

Choice A reason: Notifying the HCP immediately ensures prompt evaluation of the medication error’s impact and any needed interventions. Administering an unprescribed antibiotic risks adverse reactions or ineffective treatment. Prompt notification supports patient safety, aligns with error management protocols, and allows the HCP to adjust the care plan accordingly.

Choice B reason: Documenting in the EHR is critical but secondary to notifying the HCP. Immediate notification allows the provider to assess and mitigate harm from the unprescribed antibiotic. Documentation follows to record the error and actions taken, but delaying HCP contact risks prolonged exposure to potential adverse effects.

Choice C reason: Informing the next shift’s nurse ensures continuity but is not the priority. Notifying the HCP first addresses the immediate clinical implications of the unprescribed antibiotic. Shift reports are secondary, as the error requires prompt provider intervention to evaluate the client’s condition and prevent harm from the medication mistake.

Choice D reason: Completing an incident report is necessary for quality improvement but not the first step. Notifying the HCP ensures immediate clinical action to address the unprescribed antibiotic’s effects. Incident reports follow to analyze system issues, but patient safety requires provider notification first to manage potential adverse outcomes.

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Correct Answer is B

Explanation

Choice A reason: The client’s verbal assurance of continuing reflects motivation but not physiological tolerance. Activity intolerance is measured by objective signs like heart rate and respiratory response. Subjective statements may mask fatigue or distress, making this an unreliable indicator of the client’s ability to safely tolerate progressive ambulation.

Choice B reason: A normal heart rate range before and after ambulation indicates cardiovascular stability, a key marker of activity tolerance. Heart rate reflects the body’s response to physical demand. Stable rates suggest the client can handle ambulation without excessive strain, aligning with evidence-based assessment of endurance and safety in activity intolerance.

Choice C reason: Stopping frequently to talk may indicate social engagement or fatigue, not tolerance. Activity intolerance requires objective measures like heart rate or respiratory rate. Frequent stops could mask exertion or weakness, making this an ambiguous and unreliable assessment of the client’s ability to sustain ambulation safely.

Choice D reason: Progressing from a shuffling to deliberate gait suggests improved coordination but not necessarily activity tolerance. Gait quality does not directly measure cardiovascular or respiratory response to exertion. Heart rate stability is a more precise indicator of physiological tolerance, critical for assessing safety in clients with activity intolerance.

A. Discontinue the use of the nasal cannula. B. Place padding around the cannula tubing. C. Apply lubricant to the cannula tubing. D. Decrease the flow rate to 1 L/minute.

Correct Answer is B

Explanation

Choice A reason: Discontinuing the nasal cannula risks worsening hypoxia, as the client’s oxygen saturation is 92%. The lesion is likely from tubing pressure, not oxygen delivery. Padding addresses the skin issue without compromising oxygenation, making discontinuation an inappropriate intervention that could harm the client’s respiratory status.

Choice B reason: Placing padding around the cannula tubing prevents further pressure on the zygomatic lesion, promoting skin healing. The lesion likely results from tubing friction or pressure. This intervention maintains oxygen delivery at 4 L/minute, ensuring the client’s 92% saturation is supported while addressing the skin integrity issue effectively.

Choice C reason: Applying lubricant to the cannula tubing may reduce friction but does not address pressure causing the lesion. Lubricants are more suitable for nasal dryness. Padding is more effective, as it cushions the tubing, preventing further skin breakdown while maintaining oxygen delivery for the client’s needs.

Choice D reason: Decreasing the flow rate to 1 L/minute may worsen hypoxia, as 4 L/minute maintains 92% saturation. The lesion is due to tubing pressure, not flow rate. Padding addresses the skin issue without altering oxygen therapy, making flow reduction an ineffective and potentially harmful intervention for this scenario.

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After an IV antibiotic is started, the nurse discovers 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

The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

Correct Answer is B

Explanation

The nurse observes an open skin lesion across the right zygomatic bone of a client receiving oxygen per nasal cannula at 4 L/minute. The client’s oxygen saturation level is 92%. Which intervention should the nurse implement?

Correct Answer is B

Explanation

Which action should the nurse implement for a client with shortness of breath, dyspnea on exertion, and chest pressure?

Which intervention should the nurse implement for a client?

An older adult man comes to the clinic with a painful rash over his left abdomen. He tells the nurse that he has tried a variety of creams and ointments, but none of them have relieved his symptoms. Which action is most important for the nurse to take?

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea?

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