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 C

Explanation

A. Nurses may under delegate due to time constraints, but this is not the primary cause.

B. Under delegation can occur when nurses are hesitant to delegate tasks, but it's not due to giving too much responsibility.

C. Under delegation often happens when nurses are unsure of the competence or skills of the assistive personnel.

D. A high degree of trust in delegatees typically promotes delegation rather than under delegation.

A. A B. B C. C D. D

Correct Answer is B

Explanation

The vastus lateralis muscle, located on the lateral aspect of the thigh, is one of the preferred sites for intramuscular injections. To administer an injection at this site, one should divide the thigh into thirds from the hip to the knee and choose the middle third as the injection area. It's important to inject into the lateral muscle body, avoiding the anterior thigh. The needle should be inserted at a 90-degree angle to the skin, ensuring that it penetrates deep into the muscle tissue. This site is particularly recommended for infants and children, as it is typically well-developed and can absorb the medication effectively. For adults, the vastus lateralis is also a safe choice, especially when other sites are not available or not recommended.

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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

The nurse is aware that a cause of under delegation in client care is:

Correct Answer is C

Explanation

At which site on the diagram would the nurse give an Intramuscular injection into the vastus lateralis?

Correct Answer is B

Explanation

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