Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer medication to a client. Which of the following actions should the nurse take first?
A. Check the client's identification band.
This is an important action, but not the first one. The nurse should check the client's identification band after comparing the medication label with the MAR and before administering the medication.
B. Explain the purpose and side effects of the medication.
This is an important action, but not the first one. The nurse should explain the purpose and side effects of the medication after comparing the medication label with the MAR and before administering the medication.
C. Compare the medication label with the medication administration record (MAR).
The nurse should follow the six rights of medication administration, which include the right client, right medication, right dose, right route, right time, and right documentation. The first action the nurse should take is to compare the medication label with the MAR to ensure that they match and that the medication has been prescribed for the client.
D. Assess the client for contraindications and allergies.
This is an important action, but not the first one. The nurse should assess the client for contraindications and allergies after comparing the medication label with the MAR and before administering the medication.
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Full Explanation
The nurse should follow the six rights of medication administration, which include the right client, right medication, right dose, right route, right time, and right documentation. The first action the nurse should take is to compare the medication label with the MAR to ensure that they match and that the medication has been prescribed for the client.
A) This is an important action, but not the first one. The nurse should check the client's identification band after comparing the medication label with the MAR and before administering the medication.
B) This is an important action, but not the first one. The nurse should explain the purpose and side effects of the medication after comparing the medication label with the MAR and before administering the medication.
C) Correct. This is the first action the nurse should take to ensure that the right medication is being given to the right client.
D) This is an important action, but not the first one. The nurse should assess the client for contraindications and allergies after comparing the medication label with the MAR and before administering the medication.
Similar Questions
A nurse is reviewing a client's medication list and notices that the client is taking two medications that have a potential interaction. Which of the following actions should the nurse take?
A. Notify the provider and document the interaction in the client's chart.
This is the appropriate action for the nurse to take when a potential medication interaction is identified.
B. Hold one of the medications and administer the other one as prescribed.
This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.
C. Administer both medications as prescribed and monitor the client for adverse effects.
This is not an appropriate action. The nurse should not administer both medication as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.
D. Ask the client if they have experienced any problems with taking both medications.
Full Explanation
The nurse should notify the provider and document the interaction in the client's chart when a potential medication interaction is identified. The provider may need to adjust or change one or both of the medications to prevent if from harming the client.
A) Correct. This is the appropriate action for the nurse to take when a potential medication interaction is identified.
B) This is not an appropriate action. The nurse should not hold or alter any prescribed medications without consulting with the provider first.
C) This is not an appropriate action. The nurse should not administer both medications as prescribed without notifying the provider of the potential interaction. This could put the client at risk for adverse effects or reduced efficacy of one or both of the medications.
D) This is not an appropriate action. The nurse should not rely on the client's self-report of problems with taking both medications. The client may not be aware of or recognize all of the possible signs and symptoms of a medication interaction.
A nurse is teaching a client who has a new prescription for warfarin about safe medication practices. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will use a soft-bristled toothbrush and an electric razor to prevent bleeding."
This statement indicates that the client understands how to prevent bleeding while taking warfarin.
B. "I will eat more green leafy vegetables to increase my vitamin K intake."
This statement indicates a lack of understanding of the teaching. The client should avoid sudden changes in vitamin K intake, as this can affect the therapeutic level of warfarin and increase the risk of clotting or bleeding. Green leafy vegetables are high in vitamin K and should be consumed in consistent amounts.
C. "I will take ibuprofen instead of aspirin for pain relief."
This statement indicates a lack of understanding of the teaching. The client should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen while taking warfarin, as they can increase the risk of bleeding. The client should consult with the provider before taking any over-the-counter medications for pain relief.
D. "I will check my blood pressure regularly while taking this medication."
This statement indicates a lack of understanding of the teaching. Warfarin does not affect blood pressure directly but rather affects blood clotting. The client should monitor their international normalized ratio (INR), which measures the effectiveness of warfarin, regularly while taking this medication.
Full Explanation
Warfarin is an anticoagulant that inhibits vitamin K-dependent clotting factors and increases the risk of bleeding. The client should use a soft-bristled toothbrush and an electric razor to prevent trauma and bleeding from minor cuts or abrasions.
A) Correct. This statement indicates that the client understands how to prevent bleeding while taking warfarin.
B) This statement indicates a lack of understanding of the teaching. The client should avoid sudden changes in vitamin K intake, as this can affect the therapeutic level of warfarin and increase the risk of clotting or bleeding. Green leafy vegetables are high in vitamin K and should be consumed in consistent amounts.
C) This statement indicates a lack of understanding of the teaching. The client should avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen while taking warfarin, as they can increase the risk of bleeding. The client should consult with the provider before taking any over-the-counter medications for pain relief.
D) This statement indicates a lack of understanding of the teaching. Warfarin does not affect blood pressure directly but rather affects blood clotting. The client should monitor their international normalized ratio (INR), which measures the effectiveness of warfarin, regularly while taking this medication.
A nurse is administering an intramuscular injection to a client. Which of the following actions should the nurse take to prevent medication errors?
A. Use the Z-track method to seal the medication in the muscle.
This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.
B. Aspirate for blood before injecting the medication.
This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.
C. Massage the injection site after administering the medication.
This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.
D. Rotate the injection sites among different muscle groups.
The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.
Full Explanation
The nurse should rotate the injection sites among different muscle groups to prevent tissue damage, irritation, and absorption problems. The nurse should follow the recommended sites for intramuscular injections, such as the deltoid, ventrolateral, vastus lateralis, and dorsogluteal muscles.
A) This is not an action to prevent medication errors, but rather an action to prevent leakage of the medication from the injection site and reduce pain and irritation. The Z-track method involves pulling the skin to one side before inserting the needle and releasing it after withdrawing the needle.
B) This is not an action to prevent medication errors, but rather an action to prevent injecting the medication into a blood vessel. Aspiration involves pulling back on the plunger of the syringe before injecting the medication and checking for blood return in the syringe.
C) This is not an action to prevent medication errors, but rather an action to enhance absorption and reduce pain and irritation. Massage involves applying gentle pressure to the injection site after administering the medication.
D) Correct. This is an action to prevent medication errors by avoiding repeated injections in the same muscle group.