An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because "shots hurt.” Which action should the nurse take?

Offer assurance that this particular immunization is less painful than imagined.

Use distraction to redirect the client's attention while the nurse gives the injection.

Review the importance of receiving the immunization as a protection from disease.

Invite the client to use the syringe on a dummy before receiving the immunization.

Answer and Explanation

The Correct Answer is B

A. Offer assurance that this particular immunization is less painful than imagined: Minimizing the client’s fear may come across as dismissive and does not address the adolescent’s expressed concern about pain, which may increase anxiety rather than reduce it.

B. Use distraction to redirect the client's attention while the nurse gives the injection: Distraction techniques are effective in reducing perceived pain and anxiety during injections. Shifting the client’s focus away from the procedure helps manage the emotional response and improves the overall experience.

C. Review the importance of receiving the immunization as a protection from disease: Providing education is important, but focusing solely on the rationale does not address the immediate emotional distress related to fear of pain. It may seem unempathetic in the moment.

D. Invite the client to use the syringe on a dummy before receiving the immunization: This action might heighten the adolescent's anxiety by drawing more attention to the needle and procedure. It is not a standard or effective strategy for managing fear of injections.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Interruptions during medication administration, such as being paged for a rapid response, increase the risk of distraction and error. Medication administration should be completed before attending to other duties when possible, or the process should be restarted safely when interrupted.

B. While documentation is important, it does not prevent a medication error. It is a post-administration task and does not help in ensuring the correct dose or patient before administration.

C. Clients can often identify errors when asked to confirm their medications. For example, the client may have questioned receiving a different dose (800 mg vs. her usual 300 mg).

D. Administering medication to the wrong client is a "wrong-patient" error. Verifying at least two identifiers (e.g., name and date of birth) is a Joint Commission standard and critical to preventing such mistakes.

E. Clindamycin 800 mg is significantly larger than the client’s prescribed 300 mg dose. This discrepancy should have prompted the nurse to verify the order with the provider or pharmacist.

F. While double-checking calculations is crucial when preparing weight-based or custom doses, this situation involved a wrong dose and wrong patient, not a calculation error. The dose was pre-prepared but meant for another patient.

A. Contact the healthcare provider before obtaining the specimen. B. Obtain the specimen from the client's current bowel movement. C. Withhold specimen collection until tarry black stool is observed. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is B

Explanation

A. Contact the healthcare provider before obtaining the specimen: There is no need to notify the provider unless there is an issue affecting specimen collection. The current stool characteristics do not contraindicate proceeding with the test.

B. Obtain the specimen from the client's current bowel movement: Occult blood tests are designed to detect hidden (non-visible) blood in the stool. A sample can be obtained from any soft, formed stool, even if blood is not visibly present.

C. Withhold specimen collection until tarry black stool is observed: Tarry black stool suggests upper GI bleeding, but occult blood testing is used precisely to detect blood not visible to the eye, including in normal-appearing stool.

D. Wait to obtain the specimen until observable blood is present: Waiting for visible blood defeats the purpose of testing for occult (hidden) blood. The test should be performed on a standard sample regardless of whether blood is seen.

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An adolescent is scheduled to receive a required immunization injection. The client reports being afraid of injections because "shots hurt.” Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which medication error prevention techniques would have helped to avoid this error? Select all that apply

Correct Answer is ["A","C","D","E"]

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is B

Explanation

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