Patient Data

Exhibits

The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose.

What medication error prevention techniques would have helped to avoid this error? Select all that apply.

Compare the medication label to the order

Use at least 2 client identifiers before administering a dose

Document all medication in the electronic record as soon as it is given

Involve and educate clients in medication administration

Question unusually large or small doses F Double check all dosage calculations

Answer and Explanation

Correct Answer : C,D

Immediate documentation after drug administration ensures the everyone who comes into contact with the client is aware of what has already been done

Ensuring the client does the administration also avoids such errors. The client is able to understand and question when too many doses are given without proper explanation.

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

B. Implementing a 24-hour schedule of routine analgesic administration ensures consistent pain control and helps prevent breakthrough pain.
C. Determining the client's subjective measure of pain using a numerical pain scale allows the nurse to assess the severity of the pain and monitor changes over time, which is essential for effective pain management.
D. Providing comfort measures such as topical warm application and tactile massage can help alleviate pain and provide relief to the client. These measures are non-pharmacological interventions that can complement analgesic therapy and improve the client's comfort level.
A. Encouraging increased fluid intake can help prevent dehydration and promote overall well-being, but it may not directly address chronic pain management. However, monitoring urinary output is important for assessing hydration status and renal function.
E. Encouraging mobility and physical activity is important for maintaining overall function and preventing complications associated with immobility. However, it may not directly address chronic pain management.

A. Extend the arm at the side and rotate in circles. B. Tilt the pelvis forwards and backwards. C. Turn the head to the right and left. D. Bend the arm by flexing the ulnar to the humerus.

Correct Answer is D

Explanation

D. Hinge joints, like the elbow, allow movement primarily in one direction, similar to the opening and closing of a door. To exercise hinge joints effectively, the client should perform movements that involve bending and straightening along a single plane of motion. Flexing the ulnar to the humerus would demonstrate flexion at the elbow joint, exercising the hinge joint effectively
A. Extension of the arm at the side followed by rotation in circles engages multiple joints, including ball- and-socket joints like the shoulder joint, rather than specifically targeting hinge joints.
B. Tilting the pelvis forwards and backwards primarily involves movements of the hip joint, which is a ball-and-socket joint, rather than hinge joints.
C. Turning the head to the right and left primarily involves the cervical spine, which is a complex joint that allows for various movements including rotation, flexion, and extension. It does not primarily target hinge joints such as the elbow or knee.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is D

Explanation

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

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first

A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?