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A nurse administers a dose of metformin to a client instead of the prescribed dose of metoclopramidWhich of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Notify the provider.
- C. Check the client's blood glucose.
- D. Fill out an incident report.
Correct Answer: C
Rationale: The correct answer is C: Check the client's blood glucose. This is the first action the nurse should take because metformin is used to treat diabetes and can lower blood sugar levels. Checking the client's blood glucose will help assess if the client is experiencing hypoglycemia due to the medication error. Reporting the incident to the charge nurse (A) and filling out an incident report (D) are important steps, but assessing the client's immediate condition takes priority. Notifying the provider (B) can be done after ensuring the client's safety. The other options are not relevant to addressing the immediate concern of potential hypoglycemia.
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A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
- A. Administer the medication outside the 5 cm (2 in) radius of the umbilicus.
- B. Aspirate for blood return before injecting.
- C. Rub vigorously after the injection to promote absorption.
- D. Place a pressure dressing on the injection site to prevent bleeding.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication outside the 5 cm (2 in) radius of the umbilicus. This is because injecting heparin near the umbilicus can lead to bruising or hematoma formation. Subcutaneous injections are generally given in the fatty tissue of the abdomen, but it is important to avoid the area around the umbilicus to prevent discomfort and complications. Aspiration for blood return (B) is not necessary for subcutaneous injections as they are not typically administered into a blood vessel. Rubbing vigorously after the injection (C) is not recommended as it can cause tissue damage. Placing a pressure dressing on the injection site (D) is also unnecessary for subcutaneous injections.
Which of the following medications for pain relief can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Correct Answer: C (Acetaminophen)
Rationale:
1. Acetaminophen is a non-steroidal anti-inflammatory drug (NSAID) that does not affect platelet function.
2. Enoxaparin is an anticoagulant that works by inhibiting blood clot formation.
3. Taking acetaminophen with enoxaparin does not increase the risk of bleeding.
4. Choices A, B, and D (Ibuprofen, Naproxen sodium, Aspirin) are NSAIDs that can increase the risk of bleeding when taken with enoxaparin.
For which of the following adverse effects should the nurse instruct the client taking acetazolamide for chronic open-angle glaucoma to monitor and report?
- A. Tingling of fingers
- B. Constipation
- C. Weight gain
- D. Oliguria
Correct Answer: A
Rationale: The correct answer is A: Tingling of fingers. Acetazolamide is a diuretic commonly used to treat glaucoma. Tingling of fingers is associated with electrolyte imbalances caused by the drug's diuretic effect. This symptom may indicate hypokalemia, a potential side effect of acetazolamide. Monitoring and reporting this symptom promptly can prevent serious complications.
Other choices are incorrect because:
B: Constipation is not a common side effect of acetazolamide.
C: Weight gain is unlikely as acetazolamide is a diuretic causing fluid loss.
D: Oliguria, decreased urine output, is not a usual side effect of acetazolamide.
Which of the following laboratory results should the nurse report to the provider?
- A. A client who has a prescription for heparin and an aPTT of 90 seconds (normal range 30-40 sec)
- B. A client who has a prescription for heparin and an aPTT of 65 seconds (normal range 30-40 sec)
- C. A client who has a prescription for warfarin and an INR of 3.0 (normal range 0.8-1.1)
- D. A client who has a prescription for warfarin and an INR of 2.0 (normal range 0.8-1.1)
Correct Answer: A
Rationale: The correct answer is A. An aPTT of 90 seconds is above the normal range of 30-40 sec, indicating the client is at risk for bleeding due to excessive anticoagulation with heparin. This result should be reported to the provider immediately for further evaluation and possible adjustment of the heparin dose to prevent bleeding complications. Choices B, C, and D all fall within the normal range for their respective medications, so they do not require immediate reporting.
A nurse is caring for a client who received 0.9% sodium chloride 1 L over 4 hr instead of over 8 hr as prescribeWhich of the following information should the nurse enter as a complete documentation of the incident?
- A. IV fluid infused over 4 hr instead of the prescribed 8 hr. Client tolerated fluids well, provider notified.
- B. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
- C. 1 L of 0.9% sodium chloride completed at 0900. Client denies shortness of breath.
- D. IV fluid initiated at 0500. Lungs clear to auscultation.
- E. 0.9% sodium chloride 1 L IV infused over 4 hr. Vital signs stable, provider notified.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. This choice clearly states the key information - the type of IV fluid, volume, and duration of infusion.
2. Mentioning that vital signs were stable indicates client's safety was monitored.
3. Notifying the provider is crucial for any deviation from the prescribed treatment plan.
Incorrect Choices:
A. Fails to mention the type of IV fluid or client's vital signs, lacks detail.
C. Although it mentions the completion time, it does not address the deviation or client's tolerance.
D. Provides irrelevant information about the initiation time and lung assessment.
E. Similar to choice B, but lacks mentioning the infusion duration which is critical for documenting the incident.