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 B

Explanation

A: A nasal cannula delivers a lower concentration of oxygen, typically between 24-44% FIO2, and is used at flow rates of 1-6 L/min. It is not suitable for delivering 40-60% FIO2.

B: A simple face mask can deliver 40-60% FIO2 at flow rates of 5-8 L/min. It covers the nose and mouth, providing a higher concentration of oxygen compared to a nasal cannula.

C: An aerosol mask is used for delivering humidified oxygen or medications via nebulization. It can deliver varying concentrations of oxygen but is not specifically designed for 40-60% FIO2 at 5-8 L/min.

D: A face tent is used for patients who cannot tolerate a mask, such as those with facial trauma or claustrophobia. It provides humidified oxygen but does not deliver a precise FIO2 concentration.

A. Hold the cane on the right side to provide support for the weaker leg B. Remove the rubber tip when using the cane. C. Advance the right leg and the cane together to support the weaker leg D. Place the cane approximately 61 cm (24 in) in front of her feet before advancing

Correct Answer is A

Explanation

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

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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

Which oxygen delivery device can deliver 40-60% FIO2 and is from 5-8 L/min?

Correct Answer is B

Explanation

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client’s infection?

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

A nurse is caring for a client who has had a sedative overdose. What is the priority action in caring for this client?

A nurse is performing an admission assessment on a client. Which finding should the nurse identify as an indication that the client is dehydrated?

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse that intestinal function is returning?

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