When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?
Contact the pharmacy and confirm that the dosage is safe to administer.
Inform the charge nurse and administer the dose of the medication the provider prescribed.
Ask another nurse to verify that the dosage is appropriate for the client.
Contact the provider to question the dosage.
The Correct Answer is D
A. Contacting the pharmacy may provide information, but the nurse's primary responsibility is to clarify the prescription with the provider, as they ordered the medication.
B. Informing the charge nurse and administering the medication without verifying the dosage is inappropriate and could potentially harm the client.
C. Asking another nurse to verify the dosage is a good practice but does not address the need for clarification from the provider.
D. Contacting the provider to question the dosage is the correct action, as it ensures patient safety by confirming the appropriateness of the prescribed dose before administration.
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Correct Answer is A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.