22. Prior to administering a dose of theophylline, a nurse checks a child's serum theophylline level and notes that it is 14.2 mcg/mL. What should the nurse do? Select all that apply.
22. Prior to administering a dose of theophylline, a nurse checks a child's serum theophylline level and notes that it is 14.2 mcg/mL. What should the nurse do? Select all that apply.
. Withhold the medication and notify the pediatrician.
. Administer the medication as ordered.
. Note the serum theophylline level on the Medication Administration Record (MAR).
. Circle the theophylline dose on the Medication Administration Record (MAR) as being "withheld."
Test-Taking Tip
Two options say "don't give" (i.e., withhold) while two options say "give" (administer). Select the two options that say "give" because the blood level is within normal range. The priority is to note the blood level, then give the medication.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Laboratory Value
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Answer 1 is incorrect because the serum theophylline level should range from 10 to 20 mcg/mL. There is no need to withhold the medication because the medication level is safe. Answer 2 is correct because the serum theophylline level should range from 10 to 20 mcg/mL. It is safe to administer the medication to the child. Answer 3 is correct because the nurse should note the child's serum theophylline level on the Medication Administration Record (MAR) next to the dose and time to validate that it is safe to administer the medication to the child. It is the first action that the nurse should take. Documentation of a safe medication level always takes place prior to administration of the medication. Answer 4 is incorrect because the medication level is safe and there is no need to withhold the medication.