The nurse misreads the electronic medication administration record (MAR) and administers twice the amount of antihypertensive medication that was ordered for the client. When realizing the mistake, the first action should be to:

tell the nurse manager.

check the client's BP & HR.

notify the charge nurse & client's physician.

submit an occurrence report

Answer and Explanation

The Correct Answer is B

A. Notifying the nurse manager may be appropriate but is not the immediate action needed.

B. Checking the client's blood pressure and heart rate is the first action to assess the client's condition and any potential effects of the medication error.

C. Notifying the charge nurse and client's physician may be necessary but is not the immediate action needed before assessing the client.

D. Submitting an occurrence report is important for documenting the error but is not the immediate action needed before assessing the client.

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

Explanation

A. While a history of smoking may be relevant to the client's respiratory status, it is not directly observed in the current scenario.

B. Tachypnea (rapid breathing) and dyspnea (shortness of breath) are appropriate to document given the client's respiratory rate and complaint.

C. Orthopnea, the difficulty in breathing when lying flat, is evident from the client's statement.

D. Diaphragmatic breathing refers to a specific breathing technique and is not observed in the scenario.

E. Cheyne-Stokes respirations, a pattern of breathing characterized by alternating periods of deep and shallow breathing, are not described in the scenario.

A. the wound will require surgical debridement of the nonviable tissue at the wound edges. B. the patient requires turning and positioning every two hours. C. there is too much moisture present in the wound bed and treatment should be changed. D. this is a normal finding that indicates wound healing.

Correct Answer is C

Explanation

A. Surgical debridement may be necessary for nonviable tissue, but white skin around wound edges may indicate wound healing, not necessarily nonviable tissue.

B. Turning and positioning every two hours is important for preventing pressure ulcers but is not directly related to the presence of white skin around wound edges.

C. White skin around the edges of a wound is often indicative of maceration, which occurs when skin has been in contact with moisture for an extended period. This condition can make the skin appear lighter and feel softer, wetter, or soggier than usual. Maceration can slow down the healing process and make the skin more susceptible to infection. Therefore, it is crucial to address the excessive moisture to prevent further complications.

D. White skin around the edges of a wound is often indicative of maceration, which occurs when skin has been in contact with moisture for an extended period.

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The nurse misreads the electronic medication administration record (MAR) and administers twice the amount of antihypertensive medication that was ordered for the client. When realizing the mistake, the first action should be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:

Correct Answer is C

Explanation

The nurse must give a client an intramuscular injection of a medication which is very Irritating to the subcutaneous tissues. To attempt to minimize client discomfort, which action should the nurse take?

The nurse notes that a diuretic is listed on the client's medication administration record (MAR). It is most important for the nurse to report to the physician a serum:

In order to minimize discomfort when giving an injection to a client, the nurse should:

A physician writes an order for a medication to be administered QID. How often should the client receive the medication?

A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

An advantage of delegation in client care is that:

The client asks the nursing student to crush her medications and put them in apple sauce.Even before the student researches the medications, he knows that the tablet he cannot deliver in this manner is:

The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client.Assuming that there are no skin problems, which is the preferred site for the injection?