When given a scheduled morning medication, the patient 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?

“Go ahead and take it and then I’ll check with your doctor about it.”

“It wouldn’t be listed here if it were not ordered for you.”

“Let me check on the order first before you take it.”

“It’s listed here on the medication sheet, so you should take it.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

This choice suggests that the nurse is advising the patient to take the medication first and then check with the doctor. This is not a safe practice. The nurse should always verify any doubts or concerns before administering the medication. Administering an unfamiliar medication can lead to adverse effects if it turns out to be incorrect.

Choice B rationale:

This choice implies that if a medication is listed on the medication administration record (MAR), it must be correct. However, errors can occur when transcribing medication orders onto the MAR. Therefore, it’s crucial for the nurse to verify any concerns or doubts before administering the medication.

Choice C rationale:

This is the correct choice. If a patient expresses concern about a medication, the nurse should always check the order before administering it. This is a fundamental aspect of patient safety and medication administration. It ensures that the right patient receives the right medication at the right dose via the right route at the right time.

Choice D rationale:

This choice suggests that because the medication is listed on the medication sheet, the patient should take it. However, this does not address the patient’s concern about the unfamiliar medication. It’s important for the nurse to validate the patient’s concern and verify the medication order before administration.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Confusion can be a symptom of Diabetic Ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

Choice B rationale:

Polydipsia, or excessive thirst, is another common symptom of DKA. High blood sugar levels can cause increased urination, leading to dehydration and an increased feeling of thirst.

Choice C rationale:

A rapid pulse is also a symptom of DKA. This is because the body is trying to compensate for the low amount of fluid in your blood vessels due to dehydration.

Choice D rationale:

Clammy skin is not typically a symptom of DKA. It’s more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar) which is what occurs in DKA1.

A. “I will feel shaky.” B. “My skin will be warm and moist.” C. “I will be more thirsty than usual.” D. “My appetite will be decreased.”

Correct Answer is A

Explanation

Choice A rationale:

Hypoglycemia, also known as low blood sugar, is a condition where blood sugar levels fall below the standard range. It is often related to diabetes treatment. When blood glucose levels are too low, individuals may experience symptoms such as shakiness, which is why the statement “I will feel shaky” indicates an understanding of the manifestations of hypoglycemia.

Choice B rationale:

The statement “My skin will be warm and moist” does not accurately represent the symptoms of hypoglycemia. While sweating can be a symptom of hypoglycemia, it does not necessarily mean that the skin will feel warm and moist. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

Choice C rationale:

The statement “I will be more thirsty than usual” is more commonly associated with hyperglycemia, or high blood sugar, rather than hypoglycemia. Thirst is not typically a symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

Choice D rationale:

The statement “My appetite will be decreased” is not a typical symptom of hypoglycemia. In fact, hunger is a common symptom of low blood sugar. Therefore, this choice does not indicate a correct understanding of the manifestations of hypoglycemia.

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When given a scheduled morning medication, the patient 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing DKA?

Correct Answer is ["A","B","C"]

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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When given a scheduled morning medication, the patient 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?