The practical nurse (PN) is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the PN should further assess the prescription?
“It costs a lot of money to buy all of these pills”
“I get so tired of taking pills every day”
“At home I take my pills at 8:00 am”
“This is a new pill I have never taken before”
The Correct Answer is D
Choice A reason: The cost of medications, while a practical concern, does not indicate a need to assess the prescription’s safety or appropriateness. It reflects financial issues, not a clinical discrepancy. The PN should address cost concerns separately, but this does not warrant immediate prescription review.
Choice B reason: Frustration with daily pill-taking reflects emotional fatigue, not a clinical issue requiring prescription assessment. It may prompt adherence counseling, but it does not suggest errors in the prescription itself, such as incorrect medication or dosage, making this choice incorrect.
Choice C reason: Taking pills at 8:00 am at home versus 9:00 am in the hospital is a minor timing difference, not necessitating prescription review. Hospital schedules often differ, and this does not indicate a safety concern or error in the medication order.
Choice D reason: A new, unfamiliar pill raises concerns about potential prescription errors, allergies, or inappropriate medication. The PN must verify the prescription against the client’s history and medical record to ensure safety, as unfamiliarity may indicate a mistake or new therapy requiring confirmation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Instructing the UAP to bring a breakfast tray ensures nutritional support but is not the highest priority. Regular insulin peaks within 2–4 hours, risking hypoglycemia if not monitored. Observing for hypoglycemic symptoms takes precedence to ensure immediate safety post-administration.
Choice B reason: Observing for pallor, diaphoresis, or fatigue is critical, as these indicate hypoglycemia, a serious risk after regular insulin administration. Insulin lowers blood glucose, and rapid drops can impair brain function or cause seizures. Monitoring for these signs ensures timely intervention, prioritizing client safety.
Choice C reason: Measuring vital signs and oxygen saturation provides general data but is less specific than monitoring for hypoglycemia symptoms. Regular insulin’s rapid action increases hypoglycemic risk, and symptoms like diaphoresis are more direct indicators, making this choice secondary to targeted observation.
Choice D reason: Notifying the charge nurse of the insulin dose is routine but not urgent. The priority is monitoring for hypoglycemia, as regular insulin can cause rapid glucose drops, leading to serious complications. Immediate client observation outweighs administrative tasks in ensuring safety.
Correct Answer is C
Explanation
Choice A reason: Suggesting a snack after administering an incorrect insulin dose risks hypoglycemia, as 2 extra units can excessively lower blood glucose. Insulin dosing must match the glucose level per the sliding scale to prevent adverse effects, making this choice unsafe and reactive.
Choice B reason: Repeating the glucose level is unnecessary if the recorded level is reliable. The error lies in the drawn dose, not the glucose measurement. Correcting the dose to match the recorded glucose is more direct, as insulin dosing relies on accurate glucose data.
Choice C reason: Reducing the insulin dose by 2 units corrects the error, aligning with the sliding scale for the recorded glucose level. Excess insulin can cause hypoglycemia, affecting brain and organ function. This action ensures safe administration, preventing potentially severe metabolic consequences.
Choice D reason: Recording the discrepancy does not correct the dosing error and risks administering an unsafe dose. Documentation is secondary to ensuring the correct insulin amount is given, as 2 extra units could lead to hypoglycemia, requiring immediate correction, not just notation.
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