The nurse cares for a patient who is receiving diphenhydramine for acute rhinitis. The nurse notes that the patient has not voided for the past 12 hours.
Which action should the nurse take?

Choice A rationale

Scanning the patient's ID band confirms the identity of the patient using two identifiers, a crucial step in the "five rights" of medication administration to ensure the drug is given to the correct individual and to integrate with electronic health records.

Choice B rationale

Calling the patient's name three times is not a standard, evidence-based procedure for medication safety; standard protocol requires using at least two forms of patient identification (e.g., name, date of birth, medical record number).

Choice C rationale

Taking a screenshot of a medication order is a deviation from proper documentation and is not an essential action; the order must be viewed and verified within the secure electronic health record (EHR) or patient chart.

Choice D rationale

Assessing the patient prior to administration is essential to establish a baseline, determine if the medication is still appropriate based on the patient's current condition (e.g., vital signs, lab values), and check for contraindications.

Choice E rationale

Verifying medication allergies is a mandatory safety step to prevent life-threatening anaphylactic or hypersensitivity reactions, aligning with the "right patient" and "right drug" components of medication safety.

Choice F rationale

Performing hand hygiene (handwashing or alcohol-based hand rub) is necessary immediately before patient contact and medication preparation to comply with infection control guidelines and prevent the transmission of microorganisms.

Choice A rationale

Selective serotonin receptor agonists (SSRAs), like triptans, are used to treat acute migraine headaches by stimulating serotonin receptors, causing vasoconstriction. While the patient has chronic headaches, taking high doses of acetaminophen is associated with hepatotoxicity, not direct SSRA indications. The priority order would address potential liver damage before starting migraine-specific therapy, as SSRAs are not used for chronic, non-migraine headaches.

Choice B rationale

Docusate sodium, a stool softener, is used to prevent constipation by increasing water incorporation into the stool, making it easier to pass. Although opioids, which can cause constipation, are sometimes used for severe pain, this patient is taking acetaminophen, which does not commonly cause constipation. The primary concern with chronic, high-dose acetaminophen is potential hepatotoxicity, making liver function assessment the priority.

Choice C rationale

Chronic high-dose acetaminophen ingestion (above the maximum recommended 4,000 mg/day) puts the patient at significant risk for hepatotoxicity due to the accumulation of a toxic metabolite, N-acetyl-p-benzoquinone imine (NAPQI), which depletes hepatic glutathione stores. Alanine transaminase (ALT) and aspartate transaminase (AST) are liver enzymes; elevated levels (normal ALT is about 7 to 55 U/L and AST is about 8 to 48 U/L) are key indicators of hepatocellular damage.

Choice D rationale

A basic metabolic profile (BMP) assesses electrolytes and kidney function, while a complete blood count (CBC) evaluates formed blood elements. While helpful for a general assessment, BMP and CBC are less specific for the immediate, high-priority concern of acetaminophen-induced liver damage than ALT and AST. Acetaminophen overdose primarily targets the liver, not causing immediate, profound electrolyte or hematological derangements.