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 ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.
Correct Answer is A
Explanation
A. Requesting a prescription for an oral formulation of the medication is the appropriate action, as sublingual medications are designed to dissolve under the tongue and bypass the gastrointestinal tract, which is not feasible with an NG tube in place.
B. Administering the medication under the client's tongue is incorrect because the NG tube prevents effective absorption through the sublingual route.
C. Dissolving the medication in water and giving it through the NG tube defeats the purpose of sublingual administration and may not provide the desired therapeutic effect.
D. Administering the crushed medication through the NG tube is inappropriate for sublingual medications, as this can alter the medication's pharmacokinetics and effectiveness.