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The primary nurse went on break at 1845. The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Documentation and verification prevent errors.
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An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Send the UAP to be fitted for a particulate filter mask immediately.
- B. Instruct the UAP that a standard face mask is sufficient.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Advise the UAP to wear a standard face mask to obtain vital signs.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
Nurse’s Notes
The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath
Medical History
• Hypertension
• Heart failure
• Seasonal allergies
• Pneumonia (admitted 3 days ago)
Diagnostic Results
• White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
• C-reactive protein (CRP): 12 mg/L (<3 mg/L)
• Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
• Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
• Chest X-ray: Bilateral infiltrates
Vital Signs
• Temperature: 38.5°C (101.3°F)
• Heart rate: 110 beats per minute
• Respiratory rate: 28 breaths per minute
• Blood pressure: 140/90 mmHg
• Oxygen saturation: 88% on room air
Provider’s Prescriptions
• Administer IV antibiotics as prescribed
• Administer oxygen therapy to maintain SpO2 > 92%
• Monitor vital signs every 4 hours
• Encourage fluid intake
• Perform chest physiotherapy
Physical Examination Results
The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.
A nurse is caring for a client in the intensive care unit. Exhibits:Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
- A. Administer diuretics as prescribed, Increase oxygen flow rate, Perform chest physiotherapy, Administer bronchodilators as prescribed, Elevate the head of the bed
- B. Acute respiratory distress syndrome (ARDS),Congestive heart failure exacerbation,Hospital-acquired pneumonia,Chronic obstructive pulmonary disease (COPD) exacerbation
- C. Oxygen saturation, Blood pressure, Respiratory rate, White blood cell count, Serum creatinine
Correct Answer:
Rationale: Hospital-acquired pneumonia fits symptoms; chest physiotherapy clears secretions; oxygen saturation and WBC monitor progress.
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/25 mL'. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 5
Rationale: 200 mg ÷ (1000 mg/25 mL) = 5 mL.
A client voided clear, yellow urine.
- A. The client is dehydrated.
- B. The client has a urinary tract infection.
- C. The client has normal urine output.
- D. The client has kidney stones.
Correct Answer: C
Rationale: Clear, yellow urine indicates hydration.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.