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 A

Explanation

Choice A rationale: A DTI is a type of pressure injury that occurs when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for a prolonged period of time.

Choice B rationale: Dressing changes for a DTI would depend on the severity and characteristics of the injury, but a specific frequency is not universally prescribed. Choice C rationale: A DTI is not typically caused by overhydration but is associated with pressure-related damage to underlying tissues.

Choice D rationale: DTI is not a partial thickness injury, but rather an injury to the deep layers of tissue that may not be visible on the surface. A partial thickness injury involves damage to the epidermis and/or dermis, such as a stage 2 pressure ulcer.

A. dilute potassium elixir in juice prior to administration. B. monitor intake and output every shift C. assess the client for muscle weakness and flaccid paralysis. D. encourage intake of orange juice or a banana with each meal E. obtain a physician's order for cardiac monitoring

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.

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

Correct Answer is A

Explanation

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

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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)

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