A nurse is administering medication at the bedside. Which of the following actions should be the first priority?
Establish the identity of the client
Document the administration of the medication
Recheck the medication label
Obtain orange juice for the client to take with the medication
The Correct Answer is A
a. The first priority when administering medication is to ensure the right patient is receiving the correct drug. This follows the "rights" of medication administration, which include right patient, right drug, right dose, right route, and right time. Identifying the patient prevents medication errors.
b. Documentation is essential but should occur after administering the medication, not before confirming the correct patient and drug.
c. Rechecking the medication label is important, but it should be done before reaching the patient’s bedside. Once at the bedside, patient identification takes priority.
d. Obtaining orange juice may be necessary if the medication requires it, but ensuring the right patient receives the correct medication is the most critical initial step.
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Related Questions
Correct Answer is D
Explanation
A. The ages and relationships of household members are subjective data because they are reported by the patient and not directly measured or observed.
B. Usual dietary patterns and intake are also subjective data, as they rely on patient self-reporting rather than measurable, verifiable findings.
C. A list of herbal supplements regularly used is subjective because it depends on the patient’s recall and self-reporting rather than objective measurement.
D. Lab values are considered objective data because they are measurable, verifiable, and obtained through diagnostic testing rather than patient self-reporting. Objective data are based on observable and quantifiable factors, making them more reliable for clinical decision-making.
Correct Answer is A
Explanation
A. Schedule II drugs are controlled substances with a high potential for abuse. Proper disposal requires a witness, usually another nurse, to verify and cosign the waste to ensure accountability and prevent diversion.
B. Keeping the remaining drug in the patient’s drawer is unsafe and violates controlled substance regulations. Single-use vials should not be stored for later use.
C. While documentation of administered medication is necessary, simply recording the unused amount in the patient’s chart is insufficient. Controlled substances require proper disposal with a witness.
D. Controlled substances cannot be discarded in a general locked collection box without proper witnessing and documentation. The correct procedure is to have another nurse verify and cosign the waste before disposal.
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