After handing your client her medication, she says, "What is this blue tablet for? I have always taken a yellow pill.”. Your most appropriate action would be to:
Explain that the doctor probably changed her drug today to something more effective for her illness, and administer it.
Tell her briefly the action of the red tablet and administer it.
Withhold the drug until you have rechecked the MAR with her doctor's order sheet.
Administer the medication, but make a mental note to check on it later.
The Correct Answer is C
Choice A rationale
Administering medication without verifying the order, especially when the patient expresses concern about a change in appearance, is a breach of medication safety principles. The patient's concern highlights a potential discrepancy, and simply explaining a possible change without confirmation is unprofessional and dangerous.
Choice B rationale
This action is incorrect and dangerous. The patient stated she always takes a yellow pill, but the nurse is preparing to administer a blue tablet. Telling her the action of a "red tablet" is confusing, indicates a potential misunderstanding of the medication, and demonstrates a failure to address the patient's valid concern about the color discrepancy.
Choice C rationale
When a patient questions a medication, especially regarding its appearance, it is imperative to withhold the drug and recheck the medication administration record (MAR) against the physician's original order. This verifies that the correct medication, dose, and form are being administered, preventing potential medication errors and ensuring patient safety.
Choice D rationale
Administering the medication and making a mental note to check later is unsafe practice. A patient's concern about medication is a critical alert. Ignoring it and administering the drug first could lead to serious adverse effects if a medication error has occurred. Verification must precede administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A stat medication order signifies an immediate and urgent administration of the drug, typically within 30 minutes of the order. This is for critical situations where delay could significantly impact patient outcome, requiring prompt action rather than nurse's judgment for necessity.
Choice B rationale
A PRN (pro re nata) medication order means "as needed.”. This type of order grants the nurse professional discretion to administer the medication based on their assessment of the patient's condition and the specific criteria outlined in the order, such as pain level or fever.
Choice C rationale
A scheduled medication order involves administering the drug at regularly prescribed intervals, such as every 8 hours or once daily. The timing is predetermined, and the nurse's primary role is adherence to the schedule, with less independent judgment regarding administration necessity.
Choice D rationale
A single-dose order is for a medication to be given only once at a specific time. This is often used for preoperative medications or diagnostic procedures. Like scheduled orders, the timing is set, and the nurse's judgment about the necessity of administration is not the primary factor.
Correct Answer is D
Explanation
Choice A rationale
The abdomen, specifically 2 inches from the umbilicus, is a common site for subcutaneous injections due to the presence of ample adipose tissue, which allows for slower absorption of medications like insulin or heparin. Intradermal injections require a site with a thin epidermis and minimal subcutaneous tissue to ensure the medication remains within the dermal layer, making the abdomen unsuitable.
Choice B rationale
The anterior thigh is a common site for intramuscular injections, particularly in infants, due to the large muscle mass (vastus lateralis). While it can be used for subcutaneous injections, its muscularity and varying skin thickness make it less ideal for the precise shallow angle required for an intradermal injection, where the goal is to deposit the medication into the dermis.
Choice C rationale
The posterior upper arm, specifically the triceps area, is frequently utilized for subcutaneous injections, such as insulin or certain vaccines, because it offers sufficient subcutaneous tissue. However, similar to the anterior thigh, its anatomical characteristics with thicker skin and subcutaneous fat layers make it less optimal for the very superficial intradermal injection technique.
Choice D rationale
The upper chest, particularly below the clavicle and above the breasts, is an appropriate site for intradermal injections. This area, along with the inner forearm and upper back, has a thin epidermis and less subcutaneous tissue, which facilitates the proper placement of the medication within the dermis, allowing for the formation of a visible wheal, a key indicator of a successful intradermal injection.
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