Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?- Skildor

Question 1 of 5

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?

A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurse's notes. D. Discard the original medication administration record.

Correct Answer: C

Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.

Question 2 of 5

A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?

A. Surgery removes the disk and is the only treatment that can totally resolve the pain B. The medication regimen you previously used should be re-evaluated for dose adjustment C. Massage and hot pack treatments are less invasive and can provide temporary relief D. Acupuncture is a complementary therapy that is often effective for management of pain

Correct Answer: D

Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.

Question 3 of 5

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

A. The client's respiratory rate is 14 breaths per minute. B. The client's oxygen saturation is 92%. C. The client reports shortness of breath. D. The client's respiratory rate is 24 breaths per minute.

Correct Answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.

Question 4 of 5

A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?

A. Determine the client's sleep and activity pattern B. Obtain a prescription for the client to take when stressed C. Refer the client for a sleep study and neurological follow-up D. Teach coping strategies to use when feeling stressed

Correct Answer: D

Rationale: Teaching coping strategies is an appropriate first intervention for a client experiencing sleep difficulties and stress. It can help manage stress and improve sleep without immediately resorting to medication. By teaching coping strategies, the nurse empowers the client to address the underlying issues contributing to his sleep problems rather than just providing a temporary solution. Referring for a sleep study and neurological follow-up may be considered later if the client's sleep issues persist despite implementing coping strategies.

Question 5 of 5

Which intervention is most important when caring for a client with a chest tube?

A. Keep the drainage system at chest level. B. Ensure that the chest tube is clamped at all times. C. Strip the chest tube every shift. D. Ensure that the chest tube is connected to a water-seal drainage system.

Correct Answer: D

Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.

HESI Fundamentals Quizlet

Skildor

HESI RN

HESI RN

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