A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?

Report the concern to the charge nurse.

Question the nurse who worked the shifts in question.

Notify the pharmacy that the medication was not given.

Document the client's claim in the nurses' notes.

Answer and Explanation

The Correct Answer is A

A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.

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Correct Answer is B

Explanation

A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.
B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.
C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.
D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.

A. Ecchymoses over the buttocks and lower back B. Hirsutism on the face and chest C. Reduced skin elasticity over the hands and forearms D. Increased macules on the arms and legs

Correct Answer is A

Explanation

A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.

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A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?

Nursing Test Bank

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