Patient Data

Exhibits

The nurse pulled a bottle of potassium from the automated medication administration system. They went to the medication room to pull up the medication, and immediately went to the client's room to administer the dose. The nurse did not realize that they needed to calculate and pull the appropriate dose from the bottle and gave the entire volume for a total of 40 mEq. Which medication error prevention techniques would have helped to avoid this error? Select all that apply

Use at least 2 client identifiers before administering a dose

Document all medication as soon as it is given

Question unusually large or small doses

Double check the dosage of high risk medications with another nurse

Involve and educate clients in medication administration

Answer and Explanation

Correct Answer : C,D

A. Use at least 2 client identifiers before administering a dose – This is a critical step in preventing medication errors, but it would not have prevented the error in this scenario. The issue was with the dosage of the medication, not the identification of the client.
B. Document all medication as soon as it is given – While documentation is important for patient safety, it does not directly address the error of giving the wrong dose. Proper calculation and verification of the dose before administration are more effective in preventing this type of error.
C. Question unusually large or small doses – This is a key technique for preventing medication errors. The nurse should have questioned the unusually large dose of potassium, which was not calculated based on the client's weight and the prescribed amount. This would have alerted the nurse to the error before administering the medication.
D. Double check the dosage of high-risk medications with another nurse – Potassium is considered a high-risk medication, and double-checking the dosage with another nurse would have been an effective safety measure. This technique helps to catch errors in dosage calculations, especially with medications that have narrow therapeutic windows like potassium.
E. Involve and educate clients in medication administration – While involving and educating clients is important for overall safety and understanding, it is not a technique that would have helped prevent this particular medication error. The error was related to the nurse’s calculation and administration of the dose, not the client's involvement.

Nursing Test Bank

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Correct Answer is D

Explanation

A. "The healthcare provider will share this information with you" implies that the father has the right to access the client’s information, which is incorrect unless the client has provided explicit consent.

B. "I'm sorry, but your son's medical information is none of your business" is inappropriate and dismissive. While the father does not have automatic rights to the information, the response should be respectful and professional.

C. "I can give you those results as soon as I get them back from the lab" violates the client’s privacy, as the father is not automatically entitled to this information without the client’s consent.

D. "I can only give medical information to your son because he is an adult" is correct because the client is 19 years old and legally an adult. Under privacy laws such as HIPAA, the nurse cannot share medical information with anyone, including parents, unless the client has given permission.

A. Obtain the specimen from the client's current bowel movement. B. Withhold specimen collection until tarry black stool is observed. C. Contact the healthcare provider before obtaining the specimen. D. Wait to obtain the specimen until observable blood is present.

Correct Answer is A

Explanation

A. Obtain the specimen from the client's current bowel movement is the correct action. Occult blood can be present even in normal-appearing stool. The nurse should obtain the specimen from the current bowel movement, as it is part of the protocol for testing for hidden blood in the stool. The stool does not need to be tarry or black to test for occult blood.

B. Withhold specimen collection until tarry black stool is observed is incorrect. Tarry black stools often indicate the presence of digested blood, but occult blood testing is designed to detect blood that may not be visible to the naked eye, even in normal-colored stool.

C. Contact the healthcare provider before obtaining the specimen is unnecessary. The nurse can proceed with the collection as per the standard procedure without needing to contact the healthcare provider, unless there is a specific reason to do so.

D. Wait to obtain the specimen until observable blood is present is incorrect. The purpose of an occult blood test is to detect hidden (occult) blood, which may not be visible to the eye. The nurse should not wait for visible blood to appear before collecting the specimen.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Correct Answer is D

Explanation

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Correct Answer is A

Explanation

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, which areas should the nurse observe? Select all that apply.

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement?

The electronic medication system alerts the nurse that the medication dose scanned for the client is two times higher than the dose prescribed. Which action should the nurse implement?

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?