After the 0700 report, the day shift nurse notices that a patient has a 0730 dose of insulin due and goes to the automated dispensing machine to retrieve the insulin.
The nurse sees that the night shift nurse had removed the 0730 dose of insulin, but the medication administration record has not been signed by the nurse.
The patient is confused and says she thinks the night nurse gave her the insulin.
The patient's blood glucose level is 142 mg/dL. What will the day shift nurse do?
Give the insulin because it was not signed off.
Hold the insulin because the patient thinks she received it, and it is recorded in the machine.
Ask the charge nurse to call the night nurse at home to clarify whether the insulin was given.
Report this to the nursing supervisor.
The Correct Answer is D
Choice A rationale
Giving the insulin is not safe because there is a possibility the patient has already received it, even though the record is not signed. Administering a second dose of insulin could lead to hypoglycemia, a life-threatening condition where the blood glucose level drops dangerously low, causing symptoms like confusion, seizures, and unconsciousness.
Choice B rationale
Holding the insulin is the initial safe action, but simply holding it doesn't resolve the issue and leaves the patient's care plan incomplete. The primary concern is the potential for a double dose and the lack of proper documentation. The problem requires a more formal and structured response than simply holding the medication and moving on.
Choice C rationale
Contacting the night nurse is an option, but it is not the most immediate or appropriate action. The night nurse may be asleep or unreachable. The nurse on duty is responsible for the patient's safety and should follow proper chain of command and reporting protocols to resolve the issue promptly and ensure patient safety.
Choice D rationale
This situation involves a medication discrepancy, a potential medication error, and a significant safety risk to the patient. Reporting it to the nursing supervisor is the correct and necessary action. The supervisor can initiate a formal investigation, ensure the patient is safe, and address the documentation issue to prevent future errors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Benzodiazepines are central nervous system depressants that enhance the effect of the neurotransmitter GABA. Alcohol is also a central nervous system depressant. Combining these substances can lead to a dangerous synergistic effect, resulting in profound sedation, respiratory depression, and potentially fatal overdose. Therefore, patients must be explicitly advised to avoid alcohol.
Choice B rationale
Benzodiazepines act by enhancing the effects of gamma-aminobutyric acid (GABA), the primary inhibitory neurotransmitter in the central nervous system. This action leads to a generalized decrease in neuronal excitability, which is responsible for their anxiolytic, sedative, and hypnotic effects. As a result, common side effects include drowsiness and dizziness, which can impair a patient's ability to drive or operate machinery.
Choice C rationale
Benzodiazepine absorption is generally not significantly affected by food. While some medications may have improved absorption with meals, benzodiazepines do not require this. Taking the medication with or without food does not substantially alter its bioavailability or efficacy, so this instruction is not a necessary part of patient education regarding this drug class.
Choice D rationale
Abrupt discontinuation of benzodiazepines can lead to withdrawal symptoms, which can be severe and potentially life-threatening. These symptoms may include rebound anxiety, insomnia, seizures, and psychosis. The body adapts to the presence of the drug, and sudden removal can cause a state of hyper-excitability. Therefore, the medication should always be tapered under the guidance of a healthcare provider.
Correct Answer is B
Explanation
Choice A rationale
Serum sodium levels are important to monitor, as furosemide can cause hyponatremia (normal range 135-145 mEq/L). However, muscle weakness and dizziness are more classic signs of hypokalemia, as potassium plays a crucial role in nerve and muscle function. Therefore, potassium is the more critical value to check initially.
Choice B rationale
Furosemide is a loop diuretic that inhibits the reabsorption of sodium and chloride in the loop of Henle, leading to increased excretion of water, sodium, potassium, and chloride. The patient's symptoms of muscle weakness and dizziness are classic manifestations of hypokalemia (normal range 3.5-5.0 mEq/L), making serum potassium the most important lab value to check.
Choice C rationale
While loop diuretics can sometimes affect blood glucose levels, leading to hyperglycemia, this is not a primary concern for the immediate symptoms of muscle weakness and dizziness. These symptoms are much more indicative of an electrolyte imbalance, specifically potassium, which is directly affected by furosemide's mechanism of action.
Choice D rationale
Serum calcium levels can also be affected by furosemide, which can cause hypocalcemia. While hypocalcemia can present with muscle cramps and weakness, hypokalemia is a more common and prominent side effect of loop diuretics. Thus, checking potassium levels is the priority given the reported symptoms.
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