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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Here’s the step-by-step process:

After the first half-life (1 half-life), 50% of the initial drug is left.

200 mg → 100 mg (half is eliminated, 100 mg remains).

After the second half-life (2 half-lives), 50% of the remaining drug is eliminated again.

100 mg → 50 mg (half of 100 mg is eliminated, 50 mg remains).

After the third half-life (3 half-lives), 50% of the remaining drug is eliminated again.

50 mg → 25 mg (half of 50 mg is eliminated, 25 mg remains).

A. Problems that cause severe discomfort to the client B. Problems the client deems most important C. Problems that are immediately life-threatening for the client D. Problems that are identified as priority by the physician

Correct Answer is C

Explanation

A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.

B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.

C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.

D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.

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Laboratory Test	Result	Normal Range
Sodium	146 mEq/dL	135-145 mEq/L
Calcium	8.2 mg/dL	8.4-10.2 mg/dL
Magnesium	1.2 mg/dL	1.6-2.2 mg/dL
Gastric pH	6	1-4

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?

Nursing Test Bank

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