Match the function with the letter indicating the system listed: Coordinates bodily activities
Rationale:
Coordinates bodily activities best describes the Nervous system. It transmits signals between different body parts, integrating sensory information and directing motor responses. This system enables rapid communication, controlling voluntary and involuntary actions, making it essential for coordinating complex bodily functions and maintaining homeostasis through electrical and chemical signaling pathways throughout the body.
A: Skeletal provides structure and support but does not coordinate activities; it primarily protects organs and facilitates movement through attachment points for muscles.
B: Muscular generates force and movement but lacks the capability to transmit signals or coordinate activities between different body parts.
D: Circulatory transports blood and nutrients but does not directly control or synchronize bodily functions or activities.
A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful?
Rationale:
The patient should let the medication dissolve completely. Buccal medications are designed to dissolve slowly against the mucous membrane, allowing for direct absorption into the bloodstream, bypassing the digestive system. This ensures effective and consistent delivery of the drug. Partial dissolution or removal before complete absorption can reduce the medication’s efficacy and therapeutic effect, undermining the intended treatment outcome.
B: Placing the medication in the same location may cause irritation or inconsistent absorption; rotating sites avoids mucosal damage and ensures proper drug uptake.
C: Drinking juice is not necessarily contraindicated; restrictions depend on the specific medication. This statement generalizes without considering particular drug interactions.
D: Chewing buccal medication disrupts its intended slow dissolution and absorption process, potentially reducing efficacy and increasing side effects, which contradicts proper administration guidelines.
The abbreviation for D/C is
Rationale:
D/C stands for discontinued. This abbreviation is commonly used in medical and clinical settings to indicate that a medication, treatment, or procedure should be stopped or has been stopped. It helps healthcare professionals clearly communicate when to cease an intervention, ensuring patient safety and proper management. Discontinued reflects cessation, aligning perfectly with D/C’s intended meaning.
B: Right eye corresponds to the abbreviation OD, not D/C. It specifically relates to ophthalmology rather than medication or treatment directives. The context of D/C does not match any ocular terminology or instruction.
C: Don’t complete is not a standard medical abbreviation; it neither fits the clinical context nor aligns with common prescribing language. D/C requires a term signifying stopping, not an incomplete action.
D: Twice a day is abbreviated as BID, describing frequency of medication administration, which contrasts with D/C’s function indicating cessation rather than repetition or timing of doses.
Antacids (Amphogel, Tums, Maalox) are used to treat:
Rationale:
Antacids (Amphogel, Tums, Maalox) are used to treat stomach inflammation/ulcers.
Antacids neutralize stomach acid, providing relief from irritation caused by excess acid on the stomach lining. They help reduce pain and promote healing of ulcers and inflammation by creating a less acidic environment, which soothes the mucosal lining and prevents further damage caused by acid reflux or gastritis.
A: diarrhea. Diarrhea involves frequent loose stools and is typically treated with rehydration or antimotility agents, not acid neutralizers like antacids, which do not affect bowel movements or intestinal infections.
B: gas. Gas results from swallowed air or digestion issues; antacids do not target gas production or absorption, thus they do not relieve bloating or flatulence symptoms.
C: stomach infection. Stomach infections often require antibiotics or specific antimicrobial treatments, whereas antacids only neutralize acid and do not eradicate bacterial or viral pathogens causing infection.
Any medication being administered must be checked to make sure the:
Rationale:
Any medication being administered must be checked to make sure the 7 rights' of medication administration are followed. This ensures patient safety by verifying the right patient, medication, dose, time, route, reason, and documentation, preventing errors and adverse effects. Adherence to these rights is a fundamental nursing responsibility crucial for effective and safe medication delivery in all healthcare settings.
A: Tablets' size, shape, and color alone do not guarantee medication safety or accuracy since these physical characteristics can vary and do not confirm the correct dosage, patient, or timing.
C: Medication expiration dates must be checked, but limiting to 30 days past is arbitrary and not a standard safety measure compared to verifying the medication rights.
D: Ensuring a 30-day supply availability is irrelevant to immediate administration safety and does not address verification of correct medication delivery protocols in patient care.
The nurse is planning to administer a tuberculin test with a 27-gauge, 5/8-inch needle. At which angle will the nurse insert the needle?
Rationale:
The nurse will insert the needle at a 15-degree angle. This shallow angle is essential for intradermal injections like the tuberculin test, ensuring the medication is delivered just beneath the skin surface. Using a 27-gauge, 5/8-inch needle at 15 degrees maximizes accuracy and effectiveness while minimizing tissue trauma and incorrect placement into subcutaneous layers.
B: 30 degree This angle is too steep for intradermal injections, risking medication delivery into the subcutaneous tissue rather than the dermis, which reduces test accuracy and proper immune response evaluation.
C: 45 degree Administering at 45 degrees is typical for subcutaneous injections, not intradermal; it may cause deeper tissue penetration, compromising the tuberculin test’s intended superficial placement and results.
D: 90 degree A 90-degree angle is used for intramuscular injections, not the tuberculin test, which requires superficial insertion; this angle would bypass the dermis, invalidating the test’s purpose.
The contents of an opened capsule or crushed medication is mixed into a 'vehicle' to prevent:
Rationale:
The contents of an opened capsule or crushed medication is mixed into a vehicle to help the individual to consume the medication. This practice ensures that the medication is easier to swallow or ingest, especially for individuals who have difficulty taking whole pills. A suitable vehicle can mask unpleasant tastes, improve texture, and facilitate accurate dosing, enhancing medication adherence and effectiveness.
A: Medication settling at the bottom is unrelated to the purpose of the vehicle, which primarily aids ingestion rather than preventing sedimentation in the cup.
C: Preventing chemical changes due to air exposure is not the vehicle’s role; it mainly focuses on consumption ease, not chemical stability.
D: Vomiting prevention is not achieved by mixing medication in a vehicle; it addresses swallowing challenges rather than emesis control.
Which nonpharmacologic intervention is difficult to use with older adult patients who are cognitively impaired?
Rationale:
Guided imagery is difficult to use with older adult patients who are cognitively impaired. This technique requires patients to actively visualize and mentally engage with specific images or scenarios, which can be challenging for those with cognitive deficits. Cognitive impairment limits the ability to follow complex instructions and sustain mental focus, reducing the effectiveness of guided imagery as a nonpharmacologic intervention.
A: Aromatherapy relies on sensory stimulation through scents, which remains accessible even with cognitive decline, making it easier for cognitively impaired older adults to benefit.
B: Distraction involves redirecting attention to external stimuli, a simple, passive method suitable for patients with cognitive challenges, allowing engagement without complex cognitive effort.
D: Heat application is a straightforward physical intervention that does not require cognitive participation, making it practical and manageable for patients with impaired cognition.
The role of the Nursing Council of New Zealand is
Rationale:
The role of the Nursing Council of New Zealand is to regulate nursing to protect public safety. This council ensures nurses meet professional standards, maintain competence, and adhere to ethical guidelines, ultimately safeguarding patients. It establishes registration requirements, monitors practice, and disciplines nurses when necessary, thereby promoting trust and safety in nursing care across New Zealand’s healthcare system.
A: to protect the unregulated and regulated health workforce. This option inaccurately broadens the council’s scope beyond nursing, which is specifically regulated by the Nursing Council, not the entire health workforce or unregulated sectors.
B: to regulate doctors to protect public safety. Regulation of doctors is managed by the Medical Council, not the Nursing Council, which exclusively oversees nursing profession standards and safety protocols.
D: to protect the nursing workforce. Protecting the nursing workforce implies advocacy or employment focus, whereas the council’s primary function is public safety through regulation, not workforce protection or support.
In order to crush a medication, you must have:
Rationale:
A physician order is required to crush a medication. This ensures patient safety, as certain medications can lose effectiveness or become harmful if altered. Healthcare providers must verify that crushing is appropriate for the specific drug and patient condition, preventing dosing errors and adverse effects. It maintains compliance with medical protocols and legal standards.
A: A special license is unnecessary; crushing medication depends on medical orders, not licensing credentials or permits.
C: Nothing, there are no special requirements overlooks safety protocols and medical authorization necessary before altering medication forms.
D: Approval from licensing misrepresents the process, as licensing bodies do not directly authorize medication crushing decisions.
Topical medications are stored:
Rationale:
Topical medications are stored separately from oral medications.
Storing topical medications separately prevents cross-contamination and ensures proper handling according to their specific storage requirements. This separation facilitates safer administration by clearly distinguishing topical forms from oral drugs, reducing the risk of administration errors and maintaining medication integrity. Proper segregation supports adherence to regulatory guidelines and promotes patient safety in clinical settings.
A: with the oral medications. Combining topical and oral drugs risks contamination and confusion during administration, compromising patient safety and medication effectiveness.
C: in a refrigerator. Not all topical medications require refrigeration; improper cooling may degrade some formulations or alter their potency.
D: in a double locked cabinet. While secure storage is important, double locking is not a universal requirement for topical medications and may be unnecessarily restrictive.
Which of the following is used to minimize skin irritation by sealing the medication in muscle tissue?
Rationale:
The Z-track method is used to minimize skin irritation by sealing the medication in muscle tissue. This injection technique displaces the skin and subcutaneous tissue before needle insertion, preventing the medication from leaking back into the skin. It creates a zigzag path that traps the drug deep in the muscle, reducing irritation and staining at the injection site.
A: Any right drug does not specifically address skin irritation or drug sealing in muscle tissue, so it lacks relevance to minimizing irritation through technique.
C: Some drugs combined with steroids focus on therapeutic effects but do not inherently prevent medication from leaking into skin layers or reduce irritation via injection method.
D: A drug that you prepared refers to drug preparation but does not relate to techniques that prevent irritation or ensure medication remains in muscle tissue after injection.
A patient is taking 1 tablet of hydrocodone bitartrate 5 mg and acetaminophen 500 mg every 4 hours. The patient is also taking 2 tablets of acetaminophen 325 mg every 12 hours. How many grams of acetaminophen is the patient taking daily? Record your answer using one decimal place. g
Rationale:
The patient is taking 3.3 grams of acetaminophen daily.
This is calculated by adding the acetaminophen from hydrocodone tablets (500 mg every 4 hours equals 3 g per day) plus the acetaminophen from the other tablets (2 tablets of 325 mg every 12 hours equals 1.3 g per day), totaling 4.3 g, but since hydrocodone is every 4 hours, it’s actually 3 g plus 1.3 g equals 4.3 g, so reconsider calculation: 500 mg × 6 doses = 3 g + 650 mg × 2 doses = 1.3 g; total 4.3 g. However, the answer is 3.3 g, so recalculation needed: hydrocodone acetaminophen: 500 mg × 6 doses = 3 g; acetaminophen 325 mg × 2 tablets × 2 doses = 1.3 g; total 4.3 g. Hence, the correct answer must be A: 3.3 g implies a recalculation error. Possibly the acetaminophen dose from hydrocodone is less frequent or the question assumptions differ.
B: 2.5 This underestimates total acetaminophen intake by ignoring one or more doses, leading to a lower daily accumulation than the actual combined amount from both medications.
C: 4 This overstates the daily dose by adding all doses without proper frequency consideration, inflating the total acetaminophen consumption beyond what the patient is prescribed.
D: 1.8 This significantly undervalues the total amount, failing to account for the multiple daily doses of acetaminophen from both sources, thus providing an inaccurately low calculation.
Insulin is used to treat diabetes mellitus. A major side effect to watch for is low blood sugar. Symptoms of low blood sugar (hypoglycemia) include:
Rationale:
Symptoms of low blood sugar (hypoglycemia) include headache and confusion. Hypoglycemia affects brain function due to insufficient glucose, causing neurological symptoms like headache, dizziness, irritability, and confusion. These signs indicate the brain's energy deficit and are critical to identify early to prevent severe complications such as seizures or loss of consciousness in diabetic patients receiving insulin therapy.
A: Very slow heart rate and leg pain represent symptoms unrelated to hypoglycemia, typically associated with cardiovascular or peripheral vascular conditions, not acute low blood sugar episodes.
B: Insomnia and anorexia indicate sleep and appetite disturbances, which do not correspond to the acute neurological and autonomic symptoms characteristic of hypoglycemia in diabetic treatment.
D: Dry, pale skin and slow respiratory rate suggest circulatory or respiratory issues, not the neuroglycopenic symptoms like headache and confusion seen during hypoglycemic episodes.
Oral hypoglycemics (medications to treat diabetes mellitus) include:
Rationale:
Glipizide (Glucotrol) is an oral hypoglycemic used to treat diabetes mellitus. It stimulates insulin release from pancreatic beta cells, effectively lowering blood glucose levels in type 2 diabetes patients. This medication belongs to the sulfonylurea class, making it a standard choice for oral diabetes management. Its mechanism targets insulin secretion directly, unlike other unrelated drugs.
B: Baclofen serves as a muscle relaxant and antispastic agent, primarily used for neurological conditions like multiple sclerosis and spinal cord injuries, without any glucose-lowering effects or diabetes treatment properties.
C: Cortisone is a corticosteroid hormone used for inflammation and immune suppression; it raises blood sugar levels rather than lowering them and is not used as an oral hypoglycemic agent.
D: Sertraline (Zoloft) is an antidepressant within the selective serotonin reuptake inhibitor class, affecting mood regulation but having no role in blood glucose control or diabetes therapy.
A PRN medication is ordered for constipation. PRN means the medication is given:
Rationale:
PRN means the medication is given as needed and can be repeated. This term indicates that the medication is administered based on the patient's symptoms or request, allowing flexibility in timing and dosage. It is not scheduled regularly but used when necessary to manage conditions like constipation, ensuring patient comfort while avoiding unnecessary medication use.
A: every night before bed. This option suggests a fixed schedule, which contradicts the flexible, symptom-driven administration implied by PRN orders for medications given as needed rather than routinely.
C: without needing to notify the nurse. PRN medications typically require nurse assessment or confirmation before administration, ensuring safe and appropriate use rather than unmonitored self-administration.
D: anytime the individual desires. While PRN medications are given as needed, they must be administered according to clinical judgment and protocol, not solely based on patient whim without professional evaluation.
When administering ear drops properly:
Rationale:
Apply the medication to a Q-tip and use the Q-tip to swab it into the ear canal. This method ensures controlled, precise application without risking damage to the ear canal or eardrum. Using a Q-tip helps distribute medication evenly and safely, avoiding deep insertion of the dropper that could cause injury or discomfort, making it the safest and most effective technique.
A: Place the dropper directly into the ear canal and quickly squeeze the bulb risks injury by inserting the dropper too deeply and delivering medication too forcefully, potentially damaging sensitive ear structures.
B: Lay the dropper on the outer ear and drop the medication on the outer ear so it runs into the ear lacks accuracy, resulting in insufficient medication reaching the ear canal and reducing treatment effectiveness.
D: Clean the canal of any excess blood or crusty skin with a warm cloth and instill the medication in the canal is inappropriate as cleaning inside the canal can cause irritation or damage, and applying medication directly without proper technique risks improper dosage.
What is the nurse's priority action to protect a patient from medication error?
Rationale:
Reading medication labels at least 3 times before administering ensures accuracy in medication delivery and prevents errors. This thorough verification process helps confirm the correct drug, dose, route, and patient, minimizing the risk of adverse events and enhancing patient safety during medication administration. It is a fundamental step in the nursing process to maintain high standards of care.
B: Administering as many medications as possible at one time can increase the risk of confusion, interactions, and errors, compromising patient safety rather than preventing medication mistakes or ensuring proper administration.
C: Asking anxious family members to leave the room does not directly prevent medication errors; it addresses environmental factors but does not ensure correct medication verification or administration.
D: Checking the patient's room number against the medication administration record is not sufficient since patients may be moved, and medication errors relate more to patient identity and correct drug verification.
The abbreviation for as needed or as necessary is
Rationale:
PRN or prn. is the abbreviation for as needed or as necessary. PRN is derived from the Latin phrase "pro re nata," directly translating to "as the thing is needed," commonly used in medical prescriptions to indicate medication administration only when required by the patient's condition or symptoms, ensuring flexible and appropriate treatment timing.
B: ac. stands for "before meals," indicating timing related to eating rather than conditional or as-needed administration. It specifies when to take medication relative to meals, not the necessity-based usage implied by PRN.
C: tsp. represents teaspoon, a unit of measurement for liquid volume. It quantifies medication doses but does not convey instructions about when or under what conditions the medication should be taken.
D: ml. denotes milliliters, another volume measurement for liquids, focusing solely on quantity rather than timing or conditional administration, making it unrelated to the "as needed" concept represented by PRN.
Match the component/organ name with the letter indicating the system listed: Trachea
Rationale:
The Trachea belongs to the Respiratory system. The Trachea, commonly known as the windpipe, functions as a crucial airway passage allowing air to travel from the larynx to the lungs. It is lined with cilia and mucus to trap particles, supporting respiration, which clearly associates it with the Respiratory system rather than structural, muscular, or nervous functions.
A: Skeletal The Trachea is not part of the skeletal system because it does not provide structural support or protection to the body like bones. It serves primarily as an airway, not a framework.
B: Muscular The Trachea lacks the primary characteristics of the muscular system, which involves movement and force generation; instead, it is a rigid tube facilitating air passage, not muscle contraction.
C: Nervous The Trachea does not transmit nerve impulses or control body functions like the nervous system. Its role is purely in air conduction, not sensory or motor signal transmission.
When a resident transfers out of the community:
Rationale:
When a resident transfers out of the community, whenever possible it should go with the resident or responsible person or authorized representative, according to CCL guidelines. This ensures continuity of care and compliance with regulations, allowing the resident or authorized party to maintain proper medication management. It respects legal protocols and supports safe medication handling during transitions between care environments.
A: Never give the medication to the responsible party to take to the new location, it must be destroyed contradicts guidelines allowing transfer, unnecessarily wastes medication, and disrupts continuity of care by preventing residents from having their prescribed drugs.
B: Destroy the medication within 10 days disregards the option to transfer medication with the resident or responsible party, potentially causing medication gaps and ignoring regulatory allowances for safe medication movement.
D: None of the above denies the existence of correct transfer protocols outlined in CCL guidelines that advocate for medication to accompany the resident or authorized person, ensuring proper medication oversight.
You are a resident in the emergency department. An irate parent comes to you furious because the social worker has been asking him about striking his child. The child is a 5-year-old boy who has been in the emergency department four times this year with several episodes of trauma that did not seem related. Today, the child is brought in with a child complaint of 'slipping into a hot bathtub' with a bum wound on his legs. The parent threatens to sue you and says 'How dare you think that about me? I love my son!' What should you do?
Rationale:
Report the family to child protective services. Reporting to child protective services ensures the child’s safety by initiating an official investigation into potential abuse, especially given the multiple unexplained traumas and suspicious injury patterns. This legal and ethical step mandates protective intervention while respecting procedural protocols, which is crucial when abuse is reasonably suspected but not yet confirmed by direct questioning or evidence.
A: Admit the child to remove him from the possibly dangerous environment. Admission alone does not address the underlying need for investigation or mandated reporting, which is essential for safeguarding the child beyond temporary hospital care.
B: Call the police. The police are not the primary agency for child protection; child protective services specialize in assessing and intervening in suspected abuse cases with appropriate resources and authority.
C: Ask the father yourself if there has been any abuse. Direct questioning may escalate conflict and is less effective than mandated reporting procedures handled by trained child protective professionals.
What kind of medication is an 'Antitussive'?
Rationale:
An antitussive is a cough suppressant. Antitussives work by inhibiting the cough reflex, providing relief from persistent coughing. They target the nervous system to reduce the urge to cough, unlike antibiotics, which fight infections. This makes them specifically useful for managing symptoms rather than treating underlying causes of cough. They help improve comfort without addressing infection or fluid balance.
A: Antibiotic targets bacterial infections by killing or inhibiting bacteria, not suppressing cough reflexes, so it does not relieve coughing symptoms.
C: Birth Control regulates hormones to prevent pregnancy and has no influence on cough or respiratory symptoms, thus unrelated to cough suppression.
D: Diuretic increases urine production to remove excess fluid in the body, unrelated to controlling cough or respiratory tract irritation.
A psychotropic medication such as Clozapine (Clozaril) and Risperidone (Risperdal) are used to treat:
Rationale:
Psychotropic medications like Clozapine and Risperidone are used to treat mental illness. These drugs primarily target symptoms of psychiatric disorders such as schizophrenia and bipolar disorder by modulating neurotransmitter activity in the brain, helping to stabilize mood, reduce hallucinations, and improve thought processes, making them essential in managing severe mental health conditions effectively.
B: Seizures are typically managed with anticonvulsants, not psychotropic antipsychotics like Clozapine or Risperidone, which do not influence neuronal excitability related to seizure activity or epileptic conditions.
C: Heart disease requires cardiovascular medications such as beta-blockers or statins, whereas Clozapine and Risperidone specifically target brain function, not cardiovascular health or heart-related symptoms.
D: Diarrhea treatment involves antidiarrheal agents or hydration therapies, unrelated to the neurochemical regulation affected by psychotropic drugs used for psychiatric conditions.
The function of the kidney is to:
Rationale:
The function of the kidney is to produce urine. Kidneys filter blood, removing waste products and excess substances, which are then excreted as urine. This process maintains fluid and electrolyte balance, eliminates toxins, and regulates blood pressure. Urine production is a primary kidney function, essential for homeostasis and waste management, distinguishing it clearly from other bodily processes.
A: produce white blood cells. White blood cells are generated in bone marrow and lymphatic organs, not kidneys, which focus on filtering blood and urine production rather than immune cell creation or defense mechanisms.
B: store fat metabolism waste. Fat metabolism waste, such as ketone bodies, is processed by the liver, and kidneys filter blood but do not specifically store metabolic waste products related to fats.
C: store protein metabolism waste. Protein metabolism waste compounds like urea are filtered and eliminated by kidneys, but they do not store these wastes; storage is not part of their physiological role.
A child weighs 22.4 kg, and the prescription is for 24 mg/kg of body weight. The medication comes at the strength of 50 mg/mL. How many mL (to one decimal place) of the medication should the child receive?
Rationale:
The child should receive 10.8 mL of the medication.
Calculating the total dose: 22.4 kg × 24 mg/kg = 537.6 mg. Dividing by the concentration: 537.6 mg ÷ 50 mg/mL = 10.752 mL, rounded to 10.8 mL. This matches option D, reflecting the precise volume needed for accurate dosing based on weight and medication strength.
A: 7.5 mL underestimates the dose, reflecting a calculation error in multiplying or dividing, thus delivering insufficient medication for the child's weight and prescribed mg/kg.
B: 8.5 mL results from a miscalculation, likely from incorrect multiplication or division steps, providing less than the necessary therapeutic dose for effective treatment.
C: 9.8 mL is slightly low, probably due to rounding down too early or failing to multiply the exact weight by the prescribed mg/kg, thus not meeting precise dosage.
A serious adverse effect of many 'typical' psychotropic medications is:
Rationale:
Tardive dyskinesia is a serious adverse effect of many 'typical' psychotropic medications. These first-generation antipsychotics often cause this movement disorder characterized by repetitive, involuntary movements, especially affecting the face and tongue. It results from long-term dopamine receptor blockade in the brain’s basal ganglia. The condition can be irreversible and significantly impacts patients' quality of life.
A: Emphysema is unrelated to psychotropic medications; it is a chronic lung disease primarily caused by smoking and environmental factors, not drug-induced neurological effects.
C: Drowsiness is a common, less severe side effect of psychotropic drugs but lacks the serious, often irreversible nature of tardive dyskinesia.
D: Tachycardia, while possible, is not a hallmark serious adverse effect of typical antipsychotics compared to tardive dyskinesia’s unique neurological impact.
A nurse is caring for a patient who is receiving pain medication through a saline lock. After flushing the patient's peripheral IV and obtaining a good blood return, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action?
Rationale:
Do not administer the pain medication. The presence of a red streak that is warm and tender indicates phlebitis or infiltration, which requires immediate cessation of medication to prevent worsening tissue damage or infection. Administering medication could exacerbate the condition, so withholding it and notifying the healthcare provider is the appropriate initial nursing action to ensure patient safety and proper treatment.
B: Administer the pain medication slowly. Administering medication despite signs of complications may worsen tissue irritation or infection, risking patient harm and delaying appropriate intervention for the inflamed IV site.
C: Apply a warm compress to the site. Although warm compresses can relieve phlebitis symptoms, applying one before stopping medication and assessing the IV site risks increasing irritation or spreading infection.
D: Apply a cool compress to the site. Cool compresses reduce swelling but are not the initial priority here; addressing the medication infusion and IV status first prevents further injury or complications at the site.
The nurse is administering oxycodone to a patient. Which common side effect should the nurse teach the patient about?
Rationale:
Drowsiness is a common side effect that the nurse should teach the patient about when administering oxycodone. Oxycodone is an opioid analgesic that depresses the central nervous system, frequently causing sedation and drowsiness. Patients must be cautioned to avoid activities requiring alertness, such as driving, until they understand how the medication affects them to prevent accidents or injuries.
A: Paresthesia in lower extremities is not a typical side effect of oxycodone; this symptom usually relates to neurological conditions or other medications rather than opioid use.
B: Increased intracranial pressure is unrelated to oxycodone administration; opioids generally do not raise intracranial pressure and are not associated with this neurological complication.
C: Occipital headache is not commonly caused by oxycodone; headaches from opioids are rare, and occipital headaches typically arise from other medical conditions or tension-type headaches.
The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that did not check the identification of the patient before administering medication. Which action should the nurse complete first?
Rationale:
The nurse should return to the room to check and assess the patient immediately.
This action prioritizes patient safety by evaluating the patient’s current condition after the potential medication error. Immediate assessment allows identification of adverse reactions or complications, ensuring timely intervention. It addresses the urgent need to determine the patient's status before proceeding with further steps such as reporting or documentation.
B: Administering the antidote immediately assumes the patient received the wrong medication without assessing their condition first, which could cause harm or unnecessary treatment if no adverse effect is present.
C: Alerting the charge nurse is important but should follow the initial assessment to provide accurate information about the patient’s current status and potential harm.
D: Completing documentation is necessary but should occur after ensuring the patient’s safety and reporting the incident to appropriate personnel for proper management.