An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do?

Administer the medication and monitor the patient frequently.

Refuse to give the medication and notify the nurse supervisor.

Give the patient hydromorphone, as it was meant to be written.

Call the health care provider to clarify the order.

Answer and Explanation

The Correct Answer is D

A: Administering the medication and monitoring the patient frequently is not appropriate because phenytoin is not indicated for pain management.

B: Refusing to give the medication and notifying the nurse supervisor is a step in the right direction, but the nurse should also seek clarification from the health care provider.

C: Giving the patient hydromorphone without clarification is not appropriate. The nurse must verify the order with the health care provider.

D: Calling the health care provider to clarify the order is the correct action. This ensures that the correct medication is administered as intended.

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Correct Answer is C

Explanation

A: Calling the prescribing physician is important, but the immediate action should be to withhold the medication to prevent further elevation of potassium levels.

B: Calling the lab to verify the results can be done, but the immediate action should be to withhold the medication.

C: Omitting the KCL dose and documenting it is the correct action. The client’s potassium level is already elevated, and administering additional potassium could be harmful.

D: Giving the ordered KCL as prescribed is not appropriate because the client’s potassium level is already above the normal range.

A. The site is hurting. B. The site has started to itch. C. The site is approximated. D. The site has a mass, bluish in color.

Correct Answer is D

Explanation

A: Pain at the incision site is expected after surgery and does not necessarily indicate a complication. It is important to assess the level and nature of the pain, but pain alone is not a definitive sign of a wound healing complication.

B: Itching at the incision site can be a normal part of the healing process as the wound closes and new tissue forms. While it can be uncomfortable, it is not typically a sign of a complication.

C: An approximated incision means the edges of the wound are close together and healing well. This is a positive sign and indicates that the wound is healing properly.

D: A mass, bluish in color at the incision site, may indicate a hematoma or infection, both of which are complications of wound healing. This finding requires immediate medical attention to address the underlying issue.

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An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client’s most recent laboratory results and finds the client’s potassium level is 5.2 mEq/L. (Normal 3.5-5.0 mEq/L) Which action should the nurse take?

Correct Answer is C

Explanation

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client who has a stage pressure ulcer. Which of the following interventions should the nurse include in the plan?

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

The nurse is administering a controlled substance that falls into the category of Schedule I. Which of the following displays the appropriate abuse potential for Schedule I drugs?

Normal range for oxygen saturation via pulse oximeter is?

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client’s skin?

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize which assessment is the priority?