Which intervention is most important for the nurse to implement when administering medications?

Elevate the head of the bed to at least 45 degrees.

Use at least two different methods to identify the client.

Provide a fresh glass of water for taking the medications.

Recheck the prepared medications against the medication administration record (MAR).

Answer and Explanation

The Correct Answer is B

A. Elevating the head of the bed is important for swallowing and preventing aspiration but is secondary to ensuring correct patient identification.
B. Using at least two different methods to identify the client is the most important step to prevent medication errors. This ensures that the correct medication is given to the correct patient.
C. Providing water is helpful but not as critical as ensuring the correct patient is identified.
D. Rechecking the medications against the MAR is important but should be done in conjunction with proper patient identification.

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Correct Answer is A

Explanation

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

A. Left carotid pulse volume of 4+; right carotid pulse volume of 0. B. Left carotid artery bruit present; no bruit heard in right carotid artery. C. Left carotid artery has strong pulse; right carotid artery occluded. D. Left carotid artery occlusion present; no occlusion of right carotid artery.

Correct Answer is B

Explanation

A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.
B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.
C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.
D. A bruit indicates turbulent flow, not necessarily complete occlusion.

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Which intervention is most important for the nurse to implement when administering medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Correct Answer is B

Explanation

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