A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

When preparing the medication dosage

Directly before administering the medication

When reconciling counts of controlled substances

When removing the medication from the medication drawer

At the end of the shift

Answer and Explanation

Correct Answer : A,B,D

Correct responses:

A. When preparing the medication dosage: Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.

B. Directly before administering the medication: This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.

D. When removing the medication from the medication drawer: This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.

The other options are not directly related to verifying the medication administration record against the medication label:

C. When reconciling counts of controlled substances: This is important for ensuring accurate inventory but is not related to verifying medication administration.

E. At the end of the shift: This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.

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Correct Answer is A

Explanation

A. Assault:

Assault occurs when one person intentionally threatens or causes another person to fear that they will be touched without their consent. In this situation, the nurse is threatening to administer medication by injection (an unwanted touch) as a consequence for not swallowing pills.

B. Invasion of privacy:

Invasion of privacy involves the unauthorized intrusion into an individual's personal matters. The nurse's statement does not relate to invading the client's privacy; it involves a threat related to the administration of medication.

C. Defamation:

Defamation involves making false statements that harm the reputation of another person. The nurse's statement is not making false statements about the client but rather threatening a specific action if a behavior is not followed.

D. Battery:

Battery occurs when there is intentional physical contact with another person without their consent. While the nurse's statement involves the administration of medication, the threat itself is considered assault. If the threat is carried out, and the medication is administered against the client's will, it would then be considered battery.

A. The client is consuming 25% of their meals. B. The client coughs frequently while eating. C. The client's blood pressure is 142/94 mm Hg. D. The client leans to the left side while sitting.

Correct Answer is B

Explanation

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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