Nokea
Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?
- A. file an incident report and document the finding in the client's medical record
- B. document the finding in the client's medical record only
- C. report the incident to the nursing supervisor
- D. file an incident report but do not document the finding in the client's medical record
Correct Answer: A
Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.
You may also like to solve these questions
The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions by the nurse is correct?
- A. Administer the injection in the deltoid muscle.
- B. Massage the injection site after administration.
- C. Inject the medication into the abdomen, at least 2 inches from the umbilicus.
- D. Aspirate before injecting to check for blood return.
Correct Answer: C
Rationale: enoxaparin is administered subcutaneously in the abdomen, at least 2 inches from the umbilicus, without aspiration or massage
The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25 mL. The nurse should:
- A. Divide the amount into two injections and administer in each vastus lateralis muscle
- B. Give the medication in one injection in the dorsogluteal muscle
- C. Divide the amount in two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle
- D. Give the medication in one injection in the ventrogluteal muscle
Correct Answer: A
Rationale: For infants, volumes greater than 1 mL should be divided and administered in separate sites, such as each vastus lateralis, to reduce discomfort and ensure absorption.
A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
- A. A weight loss of 2 pounds in 1 day
- B. A serum creatinine 1.25 mg/dL
- C. Urinary output of 50 mL/hr
- D. Rising blood pressure
Correct Answer: D
Rationale: Rising blood pressure is a sign of renal transplant rejection due to impaired kidney function and fluid retention.
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.
A student nurse overhears her instructor using the term pink puffer. The student knows this term refers to a client with which condition?
- A. chronic bronchitis
- B. chronic obstructive pulmonary disease (COPD)
- C. emphysema
- D. allergic asthma
Correct Answer: C
Rationale: Pink puffer' describes emphysema patients, who maintain oxygenation (pink) but hyperventilate (puffer) due to alveolar destruction.