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A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
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A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all.
- A. Take frequent sips of water
- B. Wear sunglasses when exposed to sunlight
- C. Use a soft toothbrush when brushing teeth
- D. Take the medication with an antacid
- E. Urinate prior to taking the medication
Correct Answer: A, B, E
Rationale: The correct choices for managing anticholinergic effects of oxybutynin are A, B, and E. A: Taking frequent sips of water helps combat dry mouth, a common anticholinergic effect. B: Wearing sunglasses when exposed to sunlight helps with sensitivity to light, another anticholinergic effect. E: Urinating prior to taking the medication helps reduce urinary retention, a potential side effect.
Incorrect choices: C: Using a soft toothbrush is not directly related to managing anticholinergic effects. D: Taking the medication with an antacid may interfere with its absorption and is not recommended.
A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all.
- A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr
- B. Wear a mask when providing care within 3 ft of the client
- C. Place a surgical mask on the client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear a gown when performing care that may result in contamination from secretions
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the transmission of pertussis through respiratory droplets.
C: Placing a surgical mask on the client during transportation reduces the spread of the infection to others.
E: Wearing a gown when handling secretions helps prevent contamination and spread of the infection.
Incorrect choices:
A: Negative air pressure is not necessary for the care of a pertussis patient.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
A nurse is preparing to administer digoxin (Lanoxin) to a client who states, 'I don't want to take that med. I do not want one more pill.' Which of the following responses by the nurse is appropriate in this situation?
- A. Your physician prescribed it for you, so you really should take it.
- B. Well, let's just get it over with quickly then.
- C. Okay, I'll just give you your other meds.
- D. Tell me your concerns with taking this med.
Correct Answer: D
Rationale: Correct Answer: D. Tell me your concerns with taking this med.
Rationale: This response demonstrates therapeutic communication by acknowledging the client's feelings and encourages them to express their concerns. It shows empathy and respect for the client's autonomy in decision-making. By understanding the client's reasons for not wanting to take the medication, the nurse can address any misconceptions, provide education, and potentially find alternative solutions. This approach fosters trust and collaboration between the nurse and the client.
Incorrect choices:
A: This response is dismissive of the client's feelings and does not address the underlying concerns.
B: This response does not address the client's reluctance and may come off as insensitive.
C: This response avoids the issue at hand and does not promote open communication.
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy reserve?
- A. Fat
- B. Protein
- C. Glycogen
- D. Carbohydrates
Correct Answer: D
Rationale: The correct answer is D: Carbohydrates. Carbohydrates are the body's priority energy reserve because they are the primary source of energy for the body, especially during high-intensity activities like sports. When consumed, carbohydrates are broken down into glucose, which is used for immediate energy or stored as glycogen in muscles and the liver for later use. Fat is a long-term energy reserve but is not as readily accessible as carbohydrates for quick energy. Protein is primarily used for building and repairing tissues, not as a main energy source. Glycogen is a stored form of carbohydrates in the body, not the primary energy reserve.