The nurse administered a routine scheduled medication of Prozac (fluoxetine hydrochloride), an antidepressant, 20 mg PO to a patient. The nurse checked the medication label against the MAR when getting it out of the automatic dispensing system, again when placing the medication in a cup, and once more at the patient's bedside prior to administration. The label read 20 mg and contained a single capsule. The nurse asked the patient to state her name and administered the medication, offering the patient a drink of water. The nurse documented the administration of the medication. Which of the six rights of medication administration did the nurse violate?

The nurse administered the medication correctly.

The nurse did not have a second nurse verify the dose.

The nurse did not make the appropriate number of checks for the right drug.

The nurse did not use two patient identifiers.

Answer and Explanation

The Correct Answer is D

A) The nurse administered the medication correctly: While the nurse followed many of the correct procedures, this option overlooks the critical issue of patient identification. The nurse's adherence to the six rights is not complete without the appropriate verification of the patient’s identity.

B) The nurse did not have a second nurse verify the dose: While having a second nurse verify high-risk medications is a good practice, it is not a strict requirement for every medication. The focus should be on the established protocols for verification rather than a blanket requirement for all doses.

C) The nurse did not make the appropriate number of checks for the right drug: The nurse followed proper procedures by checking the medication label multiple times against the MAR and at the bedside. Therefore, this option does not accurately reflect any violation.

D) The nurse did not use two patient identifiers: Although the nurse asked the patient to state her name, this alone does not constitute using two identifiers. The best practice is to confirm at least two identifiers (e.g., name and date of birth) to ensure the correct patient receives the medication. This oversight is a violation of the right patient in the medication administration process.

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Correct Answer is ["A","B","D"]

Explanation

A) Notify the health care provider: It is essential to inform the healthcare provider if a

patient refuses a medication. This allows for a reassessment of the patient's treatment plan and ensures that any necessary follow-up or adjustments can be made based on the patient's refusal.

B) Determine the reason for refusal: Understanding why a patient refuses medication is crucial. It may be due to side effects, lack of understanding, personal beliefs, or concerns about the medication. Gathering this information can help the nurse address the patient’s concerns and educate them appropriately.

C) Administer the dose when the next dose is due: Administering a medication that the patient has refused would violate their rights and could be considered coercive. The patient has the right to refuse treatment, and the nurse should respect that decision rather than attempt to administer it later without consent.

D) Document the reason for refusal in the patient's health record: Accurate documentation is vital in healthcare. Recording the patient's refusal and the reason for it in their health record ensures continuity of care and provides information for other healthcare team members regarding the patient's preferences and concerns.

E) Mix it in a small amount of their food: This action is inappropriate and unethical. Coercively administering medication without the patient's consent undermines their autonomy and trust in the healthcare system. The nurse should always respect the patient’s right to refuse medication.

A. 16-year-old female, who has had vomiting and diarrhea B. 65-year-old male, who has been on high doses of antibiotics for 3 weeks C. 75-year-old female, who swallowed Caladryl lotion D. 43-year-old male, who has liver failure E. 82-year-old male, who has renal disease

Correct Answer is ["B","D","E"]

Explanation

A) 16-year-old female, who has had vomiting and diarrhea: While vomiting and diarrhea can lead to dehydration and electrolyte imbalances, this scenario alone does not directly indicate an increased risk of drug toxicity. However, it could affect drug absorption and excretion, so monitoring may be warranted.

B) 65-year-old male, who has been on high doses of antibiotics for 3 weeks: Prolonged use of high doses of antibiotics can increase the risk of toxicity, particularly if the patient has underlying kidney or liver issues. Extended antibiotic use can also disrupt normal gut flora, potentially leading to adverse effects or superinfections.

C) 75-year-old female, who swallowed Caladryl lotion: While ingesting topical medications can pose risks, it does not necessarily indicate a significant risk for systemic drug toxicity unless large quantities are involved. This patient’s risk would depend on the amount ingested and her overall health status.

D) 43-year-old male, who has liver failure: Patients with liver failure are at a heightened risk for drug toxicity because the liver plays a crucial role in drug metabolism. Impaired liver function can lead to accumulation of medications, increasing the likelihood of adverse effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

If the patient refuses a medication, what should the nurse do? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

Which of the following patients are at risk for developing drug toxicity? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

The patient is to receive 120 mg of PO Lasix (furosemide). The drug book states that the usual dosage is 20 to 40 mg. What steps should the nurse take to avoid medication errors in this situation? (Select all that apply.)

The health care provider has ordered Amoxil (amoxicillin) 0.05 g, PO tid. Drug available: The nurse should give ____ mL for each dose.

The health care provider has ordered Amikin (amikacin) 500 mg, IM q8h. Drug available: The nurse should give___mL for each dose.

The health care provider has ordered prochlorperazine (Compazine) 2.5 mg IM q4h prn. The medication available is Compazine 5 mg/mL. The nurse should give ___ mL for each dose.

How can the nurse determine a patient's history of allergies? (Select all that apply.)

The health care provider has ordered allopurinol 0.05 g PO BID. Drug available: The nurse should give _____ tablet(s) for each dose.

The home care nurse is reviewing the patient's prescribed medications. The patient reports he doesn't take his antihypertensive (blood pressure) medication anymore. What is the best response by the nurse?