1. A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was
... [Show More] inadvertently administered to another client. Which of the following actions should the nurse take first?
A. Notify the client's provider.
Rationale: The nurse should notify the client's provider to inform her of the event; however, there is another action the nurse should take first.
B. Check the client's vital signs.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should know that the action of nifedipine is to lower blood pressure. Immediately upon realizing the error, the nurse should check the client's vital signs (especially the client's blood pressure) to ensure that the client is not hypotensive as a result. Only after ensuring that the client is safe and has stable vital signs should the nurse take other actions.
C. Fill out an occurrence form.
Rationale: The nurse should fill out an occurrence form to report the event to hospital personnel; however, there is another action the nurse should take first.
D. Administer the medication to the correct client.
Rationale: The nurse should administer the medication to the correct client to fulfill the provider's prescription; however, there is another action the nurse should take first.
2. A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?
A. Institutional policies regarding routine medication administration times
Rationale: The nurse should consider institutional policies regarding routine medication administration times; however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
B. Specific characteristics of the medications
Rationale: Evidence-based practice indicates that the specific characteristics of the medications be the primary consideration of scheduling administration times. The characteristics of each medication, including the indication, onset, durations of action, and potential adverse effects and interactions, primarily determine the schedule of administration. Although an institutional policy may require that all once daily medications be administered at 0800, the nurse should be aware that some classifications of medications should only be given at bedtime, or should only be given with food. Likewise, the client's preferences, as well as the availability of each medication from the pharmacy, play important but smaller roles in determining the schedule of administration.
C. Schedule of administration that the client follows at home
Rationale: The nurse should consider the schedule of administration that the client follows at home;
however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
D. Time at which the medication can be available from the pharmacy
Rationale: The nurse should consider the time at which the medication can be available from the pharmacy; however, evidence-based practice indicates that the nurse should base medication administration times on another consideration.
3. A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions?
A. "Warm the ointment by placing the tube in glass of hot tap water."
Rationale: Eye drops that are stored in the refrigerator should come to room temperature before instillation.
The parent should not warm the ointment by placing it in glass of hot water.
B. "Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment."
Rationale: The parent should clean the eye in a direction from the inside canthus outward in order to prevent contamination of the lacrimal duct or the other eye.
C. "Discard the first bead of ointment before each application."
Rationale: The parent should discard the first bead of ointment from the tube because it is considered contaminated.
D. "Instruct your child to squeeze his eyes shut following application."
Rationale: Closing the eyes spreads the medication over the eyeball, but squeezing the eyelid shut can force out some of the medication.
4. A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls?
A. The client takes alprazolam.
Rationale: Alprazolam is a CNS depressant tha [Show Less]