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.

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Correct Answer is C

Explanation

A. "Wash your hands after each administration of eye drops" is important but not specific to the safe administration of miotic eye drops. Washing hands before administration is more relevant to preventing infection.

B. "Squeeze your eye closed after administering the drops" can force the medication out of the eye, reducing its effectiveness. Instead, the client should be instructed to close the eye gently and apply pressure to the inner canthus to prevent systemic absorption.

C. "Do not allow the dropper bottle to touch the eye" is correct because it prevents contamination of the dropper, which could lead to eye infections.

D. "Administer the medication directly on the cornea" is incorrect because eye drops should be placed in the conjunctival sac, not directly on the cornea, to minimize irritation and maximize absorption.

A. Around the nostrils. B. Bridge of the nose. C. Across the forehead. D. Over the cheeks. E. Tops of the ears.

Correct Answer is ["A","B","D","E"]

Explanation

A. Around the nostrils is a common area for skin damage when using a nasal cannula. The constant pressure and friction from the cannula tubing can cause irritation or breakdown around the nostrils.

B. Bridge of the nose is another area to assess for skin damage. The nasal cannula can cause pressure ulcers or redness on the bridge of the nose, especially if the cannula is not properly positioned or if the client wears it for prolonged periods.

C. Across the forehead is not typically an area affected by a nasal cannula. The cannula does not usually make contact with the forehead, so skin damage in this area is unlikely.

D. Over the cheeks is an important area to assess. The tubing of the nasal cannula can rub against the skin on the cheeks, causing irritation or breakdown, particularly if the tubing is too tight or not positioned correctly.

E. Tops of the ears should also be observed. The tubing of the nasal cannula can cause pressure on the ears, especially if the tubing is looped behind the ears, leading to irritation or skin breakdown.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?

Correct Answer is C

Explanation

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.

Correct Answer is ["A","B","D","E"]

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

The nurse is caring for a client who is overweight and easily becomes diaphoretic. In response to this finding, which assessment(s) should the nurse include while assisting the client with personal care? Select all that apply.

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

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?