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

Answer and Explanation

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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Correct Answer is C

Explanation

a) Clarifying the order with the charge nurse is not the correct action. The charge nurse may not be able to clarify medication orders and is not the primary contact for this issue.

b) Diluting and administering the medication by gastrostomy tube (GT) is inappropriate because the medication is ordered to be taken p.o. (by mouth), not via the tube.

c) Clarifying the order with the healthcare provider is the most appropriate step. A p.o. order is typically for oral administration, but the client has a gastrotomy tube. The nurse should clarify with the provider whether the medication can be crushed and administered via the tube or if a different route or medication form is necessary.

d) Administering the medication p.o. as ordered would not be appropriate if the client is unable to take oral medications. The nurse should verify the appropriate route of administration based on the patient's condition.

A. Ask another nurse to observe and cosign wasting the remaining drug from the vial. B. Keep the remaining amount in the patient’s drawer to give at the next dose. C. Record the amount unused in the patient’s chart. D. Dispose of the vial with the remaining drug into a locked collection box.

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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A nurse is administering medication at the bedside. Which of the following actions should be the first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a gastrotomy tube in place. The health care provider ordered the medication p.o. Which action would be appropriate for the nurse to take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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