A nurse on a busy step-down floor has finished the head-to-toe assessment on a client. The nurse is ready to perform medication administration and knows that documentation of medications happens when?
You can delegate medication documentation if you are too busy.
After the medication is administered.
Whenever you get time to sit down and document.
Within 2-4 hours of giving the medications.
The Correct Answer is B
A. You can delegate medication documentation if you are too busy: Medication documentation is part of the nurse’s professional responsibilities and accountability; delegation to unlicensed personnel for this task is generally not appropriate and risks inaccurate records.
B. After the medication is administered: Documentation should be completed at the time of administration (immediately after giving the medication) so the record accurately reflects dose, time, route, and any patient response.
C. Whenever you get time to sit down and document: Waiting until a convenient time increases the chance of omissions or errors and may compromise patient safety and continuity of care.
D. Within 2–4 hours of giving the medications: Delaying documentation for hours creates a risk of charting inaccuracies and medication errors; timely (real-time) documentation is the expected practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Stage I Pressure Ulcer: Characterized by intact skin with nonblanchable erythema (redness) only; there is no open wound or partial-thickness skin loss.
B. Stage IV Pressure Ulcer: Involves full-thickness tissue loss with exposed bone, tendon, or muscle and often deep tunneling -the pictured lesion does not show exposed deeper structures.
C. Stage II Pressure Ulcer: Presents as partial-thickness skin loss involving the epidermis and possibly superficial dermis, appearing as a shallow open ulcer with a red/pink wound bed without slough -this description matches the pictured shallow, red wound.
D. Unstageable: Occurs when full-thickness skin and tissue loss is present but the base is obscured by slough or eschar, making depth indeterminate; the wound bed in the photo is visible and not covered by slough.
Correct Answer is B
Explanation
A. It doesn't matter where the IM injection is given: Site selection matters -factors such as medication type, injection volume, patient age, and muscle mass determine the appropriate IM site (e.g., deltoid, ventrogluteal, vastus lateralis).
B. IM injections should be given using the Z-Track method: The Z-track technique is recommended for certain IM medications to displace subcutaneous tissue and prevent medication from tracking back into subcutaneous tissue, reducing irritation and leakage.
C. The site will not be sore at all after this type of injection: Some soreness or local tenderness is common after IM injections due to muscle penetration and the medication; absence of soreness is not typical for all IM injections.
D. IM injections are given at a 15-degree angle: IM injections are administered at a 90-degree angle to ensure the needle reaches muscle tissue; more shallow angles are used for subcutaneous injections.
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