At the start of the shift, the practical nurse (PN) reviews a client’s medication administration record and notes that a client has a new prescription for a diuretic to be administered at bedtime. Which action should the PN take?
Explain the purpose of the medication to the client just prior to giving the medication as scheduled
Review the prescription with the charge nurse to determine if a change in time of administration is needed
Withhold the medication until the next day for clarification when the healthcare provider (HCP) makes rounds
Administer the medication early in the day to reduce risk of disturbing the client’s nighttime sleep schedule
The Correct Answer is B
Choice A reason: Explaining the medication’s purpose is important but does not address the inappropriate bedtime dosing. Diuretics increase urination, causing nocturia and sleep disruption. Administering as scheduled without review risks client discomfort, making this choice less appropriate than verifying timing.
Choice B reason: Reviewing the prescription with the charge nurse is critical, as bedtime diuretic administration causes nocturia, disrupting sleep. Diuretics, like hydrochlorothiazide, increase urine production, and morning dosing aligns with daily activity, minimizing nighttime disturbance, ensuring safe and effective administration timing.
Choice C reason: Withholding the medication until the next day delays treatment, risking conditions like edema or hypertension. Consulting the charge nurse allows timely clarification of dosing time, ensuring therapeutic benefits without sleep disruption, making this choice overly cautious and unnecessary.
Choice D reason: Administering the diuretic early without confirmation violates protocol, as the prescription specifies bedtime. Unilateral changes risk errors, and morning dosing requires provider approval. Reviewing with the charge nurse is safer, ensuring alignment with clinical intent while addressing sleep concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Gum appearance is unrelated to carbamazepine’s side effects or sore throat. While some antiseizure drugs cause gingival hyperplasia, carbamazepine does not, and gum assessment does not clarify the sore throat’s cause, which may indicate infection or agranulocytosis, making this choice irrelevant.
Choice B reason: Bowel sounds assess gastrointestinal function, not relevant to a sore throat or carbamazepine’s effects. Sore throat may signal agranulocytosis, a rare side effect, but bowel sounds do not provide data on infection or hematologic issues, making this choice inappropriate.
Choice C reason: Carotid pulse volume evaluates cardiovascular status but is unrelated to sore throat or carbamazepine’s side effects. Sore throat may indicate infection or agranulocytosis, requiring systemic assessment like temperature, not vascular checks, making this choice irrelevant for the reported symptom.
Choice D reason: Temperature is critical, as sore throat may indicate infection or agranulocytosis, a rare but serious carbamazepine side effect causing low white blood cells. Fever suggests infection, necessitating urgent reporting. This assessment provides key data to differentiate causes, guiding timely intervention.
Correct Answer is A
Explanation
Choice A reason: Immune status is critical before administering the influenza vaccine, as immunocompromised individuals may have reduced vaccine efficacy or increased risk of adverse reactions. Conditions like HIV or chemotherapy weaken immune responses, requiring tailored vaccination strategies. Assessing immune status ensures the vaccine is safe and effective, guiding clinical decisions.
Choice B reason: While age influences vaccine type (e.g., high-dose for older adults), it is less critical than immune status for safety. Age is typically already known from records and does not directly affect immediate vaccine administration decisions. This choice is less relevant compared to immune status evaluation.
Choice C reason: Food allergies are generally irrelevant to influenza vaccines, which are not derived from food allergens. However, egg allergies may be considered for certain vaccines due to manufacturing processes, but this is distinct from food allergies broadly. This choice is incorrect as it lacks direct relevance.
Choice D reason: Gender does not impact influenza vaccine administration. Vaccine efficacy and safety are not significantly influenced by gender-specific physiological differences. This choice is incorrect, as it does not provide critical information needed to ensure the vaccine’s safety or effectiveness for the client.
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