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: Dyspnea, or difficulty breathing, can occur in various conditions but is not a primary manifestation of hypovolemia. Hypovolemia primarily affects the cardiovascular system due to reduced blood volume.

B: Increased blood pressure is not a typical manifestation of hypovolemia. In fact, hypovolemia usually leads to decreased blood pressure due to the reduced volume of circulating blood.

C: A weak pulse is a common manifestation of hypovolemia. The reduced blood volume leads to decreased cardiac output, resulting in a weak and thready pulse.

D: Decreased heart rate is not typical in hypovolemia. The body usually compensates for low blood volume by increasing the heart rate (tachycardia) to maintain adequate circulation.

A. Reposition the client at least every 2 hours. B. Clean the wound with hydrogen peroxide solution. C. Massage reddened areas with dressing changes. D. Apply a heat lamp twice a day.

Correct Answer is A

Explanation

A: Repositioning the client at least every 2 hours is crucial for preventing further pressure ulcers and promoting healing. Regular repositioning helps to relieve pressure on vulnerable areas, improve circulation, and prevent skin breakdown.

B: Cleaning the wound with hydrogen peroxide solution is not recommended. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or a gentle wound cleanser should be used instead.

C: Massaging reddened areas with dressing changes is not advisable. Massaging can cause further damage to already compromised skin and tissues. Gentle handling and avoiding pressure on these areas are more appropriate.

D: Applying a heat lamp twice a day is not a standard intervention for pressure ulcers. Heat lamps can cause burns and further damage to the skin. Maintaining a moist wound environment and using appropriate dressings are better practices.

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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 sustained blood loss. Which is a manifestation of hypovolemia?

Correct Answer is C

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?

Correct Answer is A

Explanation

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

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