nurse administers incorrect dose of medication which facts related to the incident report should the nurse document in the clients medical record
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam Test Bank

1. When administering an incorrect dose of medication, which facts related to the incident report should the nurse document in the client's medical record?

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

2. A nurse is caring for a client who is receiving morphine for pain management. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Correct answer: C

Rationale: Urinary retention is an adverse effect of morphine, as it can lead to the relaxation of the detrusor muscle and sphincter constriction in the bladder. Diaphoresis, hypotension, and tachycardia are common side effects of morphine due to its vasodilatory effects and impact on the autonomic nervous system. Diaphoresis is excessive sweating, which can be a normal response to pain or fever. Hypotension and tachycardia can occur due to morphine's vasodilatory effects and its impact on the cardiovascular system. Therefore, the presence of urinary retention would indicate the need for further assessment and intervention.

3. Which electrolyte imbalance is common in patients receiving diuretics?

Correct answer: A

Rationale: The correct answer is Hypokalemia. Diuretics, such as furosemide, commonly cause potassium loss in patients, leading to hypokalemia. This electrolyte imbalance should be closely monitored to prevent complications like cardiac arrhythmias. Hypercalcemia (Choice B) is not typically associated with diuretic use. Hyponatremia (Choice C) involves low sodium levels and can occur in conditions like syndrome of inappropriate antidiuretic hormone secretion (SIADH) but is not directly caused by diuretics. Hypermagnesemia (Choice D) is an excess of magnesium, usually not a common electrolyte imbalance induced by diuretics.

4. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

5. What is the most important assessment for a patient post-surgery?

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

Similar Questions

A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?
A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings indicates the client is developing diabetes insipidus?
A nurse is providing teaching about newborn care to a group of parents. Which of the following instructions should the nurse include?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses