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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.
B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.
C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.
D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.
Correct Answer is C
Explanation
A: Identifying the type of sedative is important for treatment but is not the immediate priority.
B: Inserting a large-bore IV catheter is necessary for administering medications and fluids but is not the first priority.
C: Ensuring an adequate airway is the priority action. Maintaining airway patency is crucial to prevent respiratory complications and ensure the client receives adequate oxygen.
D: Preparing the appropriate antagonist is important but should follow the immediate action of ensuring an adequate airway.
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