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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

A.

Place the client on contact precautions.

B.

Start a high-fiber diet.

C.

Administer an oral steroid.

D.

Make the client NPO.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.

 

Choice B rationale

 

Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.

 

Choice C rationale

 

Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.

 

Choice D rationale

 

Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.
 


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.

Choice B rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.

Choice C rationale

Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale

Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.

Choice B rationale

This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.

Choice C rationale

Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.

Choice D rationale

Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.

Choice E rationale

Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.

Choice F rationale

Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.

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