The client is to receive acetaminophen 1000 mg IV Q6 hours. Today, the nurse administered acetaminophen 1000 mg PO. Which of the 9 rights was not followed in this situation?
Right dose
Right route
Right reason
Right time
The Correct Answer is B
A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.
B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."
C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.
D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) 90 degrees: For intramuscular (IM) injections, including in the ventrogluteal site, the needle should be inserted at a 90-degree angle to ensure that the medication is deposited deep into the muscle tissue. This angle allows the needle to penetrate the skin and subcutaneous tissue directly into the muscle where it can be absorbed efficiently. The ventrogluteal site, being a large and well-muscled area, is ideal for IM injections because it is less likely to cause damage to nerves or blood vessels, and a 90-degree angle ensures proper placement of the medication.
B) 45 degrees: A 45-degree angle is commonly used for subcutaneous injections which go into the fatty tissue just beneath the skin. This angle ensures that the medication is delivered into the correct layer of tissue, allowing for slow absorption. However, when administering an IM injection, a 45-degree angle would not be deep enough to reach the muscle and could result in improper placement, potentially affecting the medication's effectiveness and increasing the risk of irritation at the injection site.
C) 15 degrees: A 15-degree angle is far too shallow for an intramuscular injection and is typically used for intradermal injections, where the medication is injected just beneath the skin into the dermal layer. Using such a shallow angle for an IM injection would likely cause the needle to remain in the subcutaneous tissue, preventing the medication from reaching the muscle layer and significantly reducing its effectiveness.
D) 60 degrees: A 60-degree angle is too steep for intramuscular injections. At this angle, the needle may not effectively reach the muscle tissue and could cause the medication to be injected too superficially into the subcutaneous layer. This would not allow for proper absorption of the drug and may lead to irritation or a delayed therapeutic effect.
Correct Answer is ["20"]
Explanation
1. Determine the concentration of the guaifenesin:
The label states 100 mg/5 mL.
2. Set up a proportion to find the volume (in mL) needed:
100 mg / 5 mL = 400 mg / x mL
3. Solve for x:
Cross-multiply: 100x = 400 * 5
100x = 2000
x = 2000 / 100
x = 20 mL
Answer: The nurse will administer 20 mL to the client.
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