The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:

tell the nurse manager.

notify the physician.

check the client's blood pressure.

file an incident report.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Telling the nurse manager is not the first action; the immediate focus should be on the client's well-being.

Choice B rationale: Notifying the physician is important, but the immediate concern is addressing the client's condition.

Choice C rationale: Checking the client's blood pressure is the first action to assess the client's response to the medication error.

Choice D rationale: Filing an incident report is important for documenting the error but is not the immediate action in this situation.

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Correct Answer is C

Explanation

Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites.

Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve.

Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle.

Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

A. has a wound that is bleeding. B. has impaired sensation. C. is experiencing spasms of the calf muscles. D. has an active, localized inflammation.

Correct Answer is C

Explanation

Choice A rationale: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.

Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.

Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.

Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.

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The nurse misreads the medication Kardex and administers twice the amount of antihypertensive medication that was ordered for the client. When she realizes the mistake, her first action should be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

The nurse recognizes that the application of heat therapy is appropriate for which client? The client who:

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 reduce irritation of the tissues, which action should the nurse take?

A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

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

When doing the client's skin assessment, the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse, who stages the wound as a dropdown pressure ulcer.

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

An adult client is to receive ear drops four times a day to treat an inner ear infection. What is the correct nursing procedure to follow when administering this type of medication?