The nurse has been caring for Mr. Robertson for the past two days. On the third day. the nurse is responsible for administering Mr. Robertson's 0730 insulin. The nurse notes that Mr. Robertson does not have an armband. How should the nurse respond?
Proceed with the administration of the medication as the nurse has been caring for Mr. Robertson for the past two days
Ask Mr. Robertson to state his full name, home address, phone number and date of birth
Verify with a colleague that the client is indeed Mr. Robertson
Return to the nursing station and have a new armband made
The Correct Answer is D
A. Proceed with the administration of the medication as the nurse has been caring for Mr. Robertson for the past two days: Prior familiarity with a patient does not replace proper identification. Administering insulin without verification of identity risks serious medication errors, including giving the wrong dose to the wrong patient.
B. Ask Mr. Robertson to state his full name, home address, phone number and date of birth: While obtaining verbal identifiers is part of patient verification, relying solely on self-report is insufficient, especially in cases of cognitive impairment or altered mental status. Two independent identifiers are required, and an armband is a primary identifier.
C. Verify with a colleague that the client is indeed Mr. Robertson: Colleague confirmation is not adequate without objective verification from a source document or armband. Peer confirmation cannot legally replace proper patient identification procedures for medication administration.
D. Return to the nursing station and have a new armband made: The correct action is to ensure the patient has an updated identification armband before administering any medication. This guarantees adherence to the “right patient” safety standard, prevents medication errors, and complies with legal and institutional policies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Enteric-coated: Enteric-coated tablets are designed to resist stomach acid and dissolve in the intestines. Crushing them destroys the coating, which can result in gastric irritation, reduced efficacy, or toxicity. Therefore, these should never be crushed for enteral administration.
B. Tablet: Regular tablets without special coatings can usually be crushed and administered via an enteral tube. Crushing allows the medication to be dissolved or suspended for safe passage through the tube while maintaining therapeutic effect, provided the drug’s properties are compatible with enteral administration.
C. Buccal: Buccal medications are intended to dissolve slowly in the mouth for systemic absorption through the oral mucosa. Crushing buccal tablets for enteral administration alters absorption, onset, and effectiveness, making this inappropriate.
D. Sustained-release: Sustained-release (extended-release) formulations are designed to release the drug gradually over time. Crushing them results in rapid release of the full dose, increasing the risk of toxicity and reducing the intended therapeutic effect.
Correct Answer is D
Explanation
A. 1 inch needle: A 1-inch needle may be too long for clients with minimal subcutaneous tissue, risking inadvertent intramuscular injection, which can alter drug absorption and increase discomfort.
B. 1.5 inch needle: This length is typically used for intramuscular injections in adults and is not appropriate for subcutaneous administration in thin or elderly clients due to the risk of injecting into muscle.
C. 1/2 inch: While shorter than 1 inch, a 1/2 inch needle may still be too long for some elderly clients with very thin subcutaneous layers. Proper technique must ensure the medication remains in the subcutaneous tissue.
D. 5/8 inch: A 5/8-inch needle is generally recommended for subcutaneous injections in clients with minimal subcutaneous tissue. This length allows for accurate delivery into the fatty layer while minimizing the risk of intramuscular injection and reducing discomfort.
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