which of the following constitutes the five rights of medication administration

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. Which of the following constitutes the five rights of medication administration?

A. Right client, right nurse, right time, right dose, right route
B. Right client, right time, right dose, right route, right order
C. Right client, right drug, right dose, right time, right route
D. Right physician, right nurse, right client, right drug, right dose

Correct answer: C

Rationale: The five rights of medication administration are essential to ensure safe and effective drug delivery to clients. The correct answer includes ensuring the right client receives the right drug at the right dose, via the right route, and at the right time. These elements are crucial to prevent medication errors and ensure optimal therapeutic outcomes. Choice A is incorrect as it includes 'right nurse' which is not part of the five rights of medication administration. Choice B is incorrect as it includes 'right order' which is not part of the five rights. Choice C is incorrect as it includes 'right drug' and 'right route', but it lacks 'right client' and 'right time'. Choice D is incorrect as it includes 'right physician' which is not part of the five rights.

2. Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?

A. Standard Precautions apply to all body fluids, except sweat.
B. Alcohol-based hand rub should be used if hands are not visibly dirty.
C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.

Correct answer: C

Rationale: Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.

3. The Sims' position is MOST similar to the ________ position.

A. prone
B. lateral
C. supine
D. Fowler's

Correct answer: B

Rationale: The correct answer is 'lateral.' The Sims' position is characterized by the patient lying on their side with the upper knee flexed and the upper arm positioned in front of the body. This is similar to the lateral position where the patient is also lying on their side. The prone position (choice A) is when the patient lies face down, the supine position (choice C) is when the patient lies face up, and Fowler's position (choice D) is a seated position with the head of the bed elevated at a 45-90 degree angle. Therefore, the lateral position is the most similar to the Sims' position as both involve the patient lying on their side.

4. A nurse is completing an incident report about a medication error that she made when she accidentally administered too much insulin to a diabetic client. All of the following are components of this documentation EXCEPT:

A. The reason for administering the wrong dose
B. The type of drug involved
C. The amount of insulin that was given
D. Any adverse effects on the client

Correct answer: A

Rationale: When completing an incident report for a medication error, it is essential to include factual information such as the type of drug involved, the amount administered, and any adverse effects on the client. However, stating the reason for administering the wrong dose should be avoided in documentation. The focus should be on reporting what happened rather than assigning blame or admitting fault. This approach helps in ensuring a thorough and accurate account of the medication error without introducing subjective elements that could complicate the investigation or resolution process. Therefore, the correct answer is 'The reason for administering the wrong dose.' Choices A, B, and D are vital components of incident report documentation, providing crucial details that help in understanding the error and its impact on the client.

5. In which of these patients would rectal temperatures be measured?

A. Older adult
B. Critically ill patient
C. School-age child
D. Patient receiving oxygen via nasal cannula

Correct answer: B

Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.