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","E"]

Explanation

Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.

Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.

Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.

Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.

Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.

A. Shared responsibility B. Mutual independence C. Working in the same department D. Common purpose

Correct Answer is C

Explanation

Choice A rationale: Shared responsibility is a necessary feature of a team, promoting collaboration and achievement of common goals.

Choice B rationale: Mutual independence allows team members to work together while maintaining individual contributions.

Choice C rationale: Working in the same department is not a necessary feature of a team. Teams can be effective regardless of their physical proximity.

Choice D rationale: Common purpose is essential for a team to work cohesively toward shared goals.

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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

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

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

Explanation

The nurse recognizes that which is not a necessary feature of a team?

Correct Answer is C

Explanation

A group that has transformed itself from a collection of individuals into a productive, problem-solving highly functioning team would be functioning in which stage of group development?

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