When given a scheduled morning medication, the client states, "I haven't seen that pill before. Are you sure it's correct?" The nurse checks the medication administration record and verifies that it is listed. Which is the nurse's best response?
If you do not take it now, it will put you behind schedule."
Let me check the original order before you take it.
'It wouldn't be listed here if it were not ordered for you!"
It's listed here on the medication sheet, so you should
The Correct Answer is B
A) "If you do not take it now, it will put you behind schedule.": While the nurse might be concerned about the medication schedule, this response dismisses the client's concern and doesn’t prioritize safety. The nurse should not pressure the client to take the medication before verifying that it is correct.
B) "Let me check the original order before you take it.": This is the best response because it demonstrates a commitment to patient safety. If the client is concerned about the medication, the nurse should take the time to verify the order directly from the original source to ensure the right medication is being given. This approach reassures the client and promotes trust.
C) "It wouldn't be listed here if it were not ordered for you!": This response can come across as dismissive and unprofessional. While it is important that the medication appears on the record, the nurse should still verify it to address the client's concern. Simply relying on the medication record without confirmation is not the best course of action.
D) "It's listed here on the medication sheet, so you should take it.": Similar to option C, this response dismisses the client’s concern and does not prioritize verifying the medication’s accuracy. It could lead to the client feeling their concerns were not taken seriously, which could negatively impact their trust in the care provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.
B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."
C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.
D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.
Correct Answer is C
Explanation
A) Shake bottle well, pull ear outward and downward, instill drops: This method is typically used for younger children, such as infants or toddlers, as the ear canal in younger children is more horizontal. However, this is not the appropriate method for a 12-year-old.
B) Shake bottle well, pull ear outward and upward, instill drops: This method is incorrect because the ear should be pulled outward and upward for a child under 3 years old, not for a 12-year-old.
C) Warm bottle in hand, pull ear outward and upward, instill drops: This is the correct method for a 12-year-old client. The ear should be pulled outward and upward to straighten the ear canal, allowing the drops to reach the deeper parts of the ear. Additionally, warming the bottle in your hands prevents discomfort that might arise from cold drops being instilled in the ear.
D) Warm bottle in hand, pull ear outward and downward, instill drops: This method is appropriate for children under 3 years old. For children older than 3 years, the ear should be pulled upward to open the ear canal.
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