Nokea
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Complete an adverse occurrence report.
- B. Obtain blood for coagulation studies.
- C. Monitor for signs of bleeding.
- D. Notify the healthcare provider.
Correct Answer: D
Rationale: Notifying the provider is critical to address the high bleeding risk from the medication error.
You may also like to solve these questions
The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
- A. 30 mL of serous fluid obtained from compression bulb device in last 4 hours.
- B. 40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
- C. 20 mL of serosanguinous drainage from chest tube in last 8 hours.
- D. No observable drainage from 3-day-old Penrose drain in last 8 hours.
Correct Answer: D
Rationale: No drainage from a Penrose drain may indicate obstruction or infection, requiring immediate assessment.
A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Provide the UAP with the infection control policy.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Determine the UAP's knowledge about HIV transmission.
- D. Demonstrate the proper use of personal protective equipment.
Correct Answer: C
Rationale: Determining the UAP's knowledge about HIV transmission is the first action to address their fear, identify misconceptions, and provide targeted education.
An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
- A. Police department wants to be notified when the client is alert.
- B. Neurovascular assessments below the fracture are normal.
- C. No nausea or vomiting during the PACU recovery stay.
- D. The family is requesting a private room when one is available.
Correct Answer: B
Rationale: Normal neurovascular assessments are critical to ensure no complications post-surgery.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.
An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family?
- A. The client is grieving normally in response to her husband's death and hospitalization is not necessary.
- B. Managed care providers have mandatory pre-certification requirements for hospitalization.
- C. Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital.
- D. Managed healthcare plans do not pay for any in-hospital medical evaluations.
Correct Answer: B
Rationale: Informing the family about pre-certification requirements explains the process for hospital admission under the managed care plan.