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 B

Explanation

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

A. Identify effective pain relief measures. B. Provide a numeric pain scale. C. Observe body language and movement. D. Ask the client to describe the pain.

Correct Answer is D

Explanation

A. Identify effective pain relief measures is important but not the first step in assessing pain quality. The nurse must first assess the pain itself before determining what interventions are effective.

B. Provide a numeric pain scale is commonly used to assess the intensity of pain, but it does not address the quality of pain. The numeric scale helps measure the severity, but it does not capture how the pain feels.

C. Observe body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain's quality. While useful for assessing nonverbal clients, this approach alone does not provide detailed information about the pain experience.
D. Ask the client to describe the pain is the best approach for assessing the quality of pain. By asking the client to describe the pain, the nurse can gather information about its characteristics, such as sharp, dull, burning, or aching, which provides insight into the nature of the pain and helps guide appropriate interventions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Correct Answer is B

Explanation

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is D

Explanation

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?

The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

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 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?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

Exhibits Which other recommendation(s) could the nurse give to help the client have better sleep? Select all that apply.