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?
Place the client on contact precautions.
Start a high-fiber diet.
Administer an oral steroid.
Make the client NPO.
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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.
Correct Answer is C
Explanation
Choice A rationale
The client is dehydrated. Dehydration typically results in concentrated, dark yellow urine. Clear, yellow urine indicates that the client is well-hydrated and not dehydrated. Dehydration would cause the urine to be more concentrated and darker in color due to the reduced volume of water in the body.
Choice B rationale
The client has a urinary tract infection. A urinary tract infection (UTI) often causes urine to appear cloudy, foul-smelling, or tinged with blood. Clear, yellow urine is not indicative of a UTI. UTIs are usually associated with symptoms such as pain or burning during urination, frequent urination, and cloudy or bloody urine.
Choice C rationale
The client has normal urine output. Clear, yellow urine is a sign of normal urine output and indicates that the client is well-hydrated. Normal urine color ranges from pale yellow to amber, depending on the concentration of the urine. Clear, yellow urine suggests that the client is drinking an adequate amount of water and maintaining proper hydration.
Choice D rationale
The client has kidney stones. Kidney stones can cause urine to appear cloudy, pink, red, or brown due to the presence of blood. Clear, yellow urine is not indicative of kidney stones. Symptoms of kidney stones include severe pain in the back or side, blood in the urine, and frequent urination. Clear, yellow urine suggests that the client does not have kidney stones.