Just as the nurse is about to go document Mrs. Doe's PRN Percocet, a colleague asks for assistance to ambulate a client in the same room. How does the nurse respond?
Help the colleague first, then immediately document the medication
Ask the charge nurse to document the medication, then assist the colleague
Document the medication first, then help the colleague
This is not a concern as medication documentation is done just before administering the drug
The Correct Answer is C
Rationale:
A. Helping the colleague first delays documentation, increasing the risk of forgetting or inaccurately recording the medication.
B. Documentation is the responsibility of the administering nurse; it should not be delegated to the charge nurse.
C. Medication administration must always be documented immediately after giving to ensure accuracy and patient safety, before attending to other tasks.
D. Documentation is never done before administration; it is done right after the drug is given, so this statement is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The unit manager is not responsible for interpreting prescriber orders and should not be relied upon for this task.
B. The unit secretary is not qualified to interpret medical orders.
C. The nurse must call the prescriber directly to clarify any unclear or illegible order. Administering medication without a clear order is unsafe and could result in serious errors.
D. Pharmacists can clarify medication details but cannot interpret illegible handwriting; the prescriber must provide clarification.
Correct Answer is B
Explanation
Rationale:
A. Asking the patient to cough is appropriate if the tube has entered the airway, but it is not the first action when resistance is encountered.
B. Withdrawing the tube to the nasopharynx is the correct action. Resistance usually means the tube has hit an obstruction (e.g., nasal passage, turbinates, or esophagus). Pulling back allows for repositioning and reinsertion without causing trauma.
C. Encouraging the patient to swallow is helpful after the tube has passed the oropharynx but not when resistance is met during early insertion.
D. Hyperextending the neck makes passage into the esophagus more difficult; flexion of the neck is recommended during insertion.
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