Which action by the newly licensed nurse should prompt the charge nurse to intervene?
Verifies the medication against the prescription and medication label.
Documents medication administration prior to administering.
Scans the bar code on the medication administration record and the client's arm band.
Checks the provider's orders and confirmed dosage in a medication reference.
The Correct Answer is B
Choice A reason: Verifying the medication against the prescription and medication label is an essential safety step in medication administration. This practice ensures that the right medication is given to the right patient at the right dose, time, and route. Thus, this action should not prompt an intervention.
Choice B reason: Documenting medication administration prior to actually administering the medication is a dangerous practice. It can lead to inaccuracies in medical records and potential medication errors if the medication is not administered as documented. This is why the charge nurse should intervene to correct this practice.
Choice C reason: Scanning the bar code on the medication administration record and the client's arm band is a crucial step in the medication administration process. It helps ensure that the correct medication is given to the correct patient by electronically verifying the match between the medication and the patient's identification. This action is appropriate and should not prompt intervention.
Choice D reason: Checking the provider's orders and confirming the dosage in a medication reference is a critical safety measure. It ensures that the medication is being administered as prescribed and at the correct dose. This action is also correct and does not warrant intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
For clients with hemiparesis, the cane should be held on the stronger side (the right side in this case) to provide support for the weaker leg (left leg). This technique helps distribute weight more effectively and enhances stability, making ambulation safer for the client.
Choice B reason:
Removing the rubber tip from the cane is incorrect and unsafe. The rubber tip provides traction and prevents the cane from slipping on various surfaces. Removing it would increase the risk of falls and injuries, so this instruction should not be included.
Choice C reason:
The correct technique is to advance the cane and the weaker leg together, not the stronger leg. Advancing the right leg (stronger leg) and the cane together does not provide appropriate support for the weaker leg (left leg) and can compromise balance and stability.
Choice D reason:
Placing the cane approximately 61 cm (24 in) in front of the feet is too far and impractical. The cane should be placed a reasonable distance (approximately 15-30 cm or 6-12 in) ahead of the feet to maintain balance and stability without overreaching.
Correct Answer is B
Explanation
Choice A reason:
Administering a bolus of medication is often considered when a patient’s pain is inadequately controlled. However, in the context of a PCA (patient-controlled analgesia) pump, the first step should always be to assess the current setup and functioning of the equipment. Directly administering a bolus without checking the equipment could lead to overmedication if the pump is malfunctioning or if the patient has already received an appropriate dose that wasn’t recorded due to technical issues. Therefore, while this step might be necessary eventually, it’s not the first priority.
Choice B reason:
Checking the display on the pump is the most critical initial action. This step ensures the PCA pump is functioning correctly and delivering the correct dosage as prescribed. PCA pumps can malfunction or have technical errors, which might lead to inadequate pain control. By checking the display, the nurse can verify if the pump settings are correct, if the medication is being delivered properly, and if there are any alarms or errors that need addressing. This assessment helps to ensure patient safety and proper pain management before considering additional interventions.
Choice C reason:
Obtaining an order for another pain medication for breakthrough pain is a necessary step when the current medication regimen is insufficient to control the patient's pain. Breakthrough pain requires timely and effective management, often needing additional or alternative analgesics. However, before making this decision, the nurse must confirm that the PCA pump is functioning correctly and that the current pain management plan is being followed properly. If the pump is not working as intended, additional medication might not be necessary.
Choice D reason:
Encouraging the client to administer a demand dose is part of the standard protocol for using PCA pumps, allowing patients to manage their pain actively. However, this action assumes the pump is functioning correctly. If there are issues with the pump, encouraging the patient to administer more doses won’t be effective and could potentially cause harm. Therefore, it is essential to first verify the pump’s functionality to ensure that the patient’s self-administered doses are being delivered as intended.
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