The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which phase of the nursing process?
Assessment
Evaluation
Implementation
Planning
The Correct Answer is A
A. Assessment is the first phase of the nursing process, during which the nurse gathers relevant patient data, such as allergies and lab values, to ensure safe medication administration. This step helps identify potential risks and contraindications.
B. Evaluation occurs after the medication has been administered and involves assessing the patient's response to the drug. In this case, the nurse is reviewing information before administration, making evaluation an incorrect choice.
C. Implementation refers to carrying out the nursing interventions, such as actually administering the medication. Since the nurse is still reviewing data, this step has not yet been reached.
D. Planning involves setting goals and determining appropriate interventions, but it does not include the direct collection of patient data. Reviewing lab values and allergies falls under the assessment phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. C-V drugs are considered to have the lowest potential for abuse and are typically used for medications like cough preparations with less than 200 milligrams of codeine per 100 milliliters or per 100 grams. Methadone is not classified under C-V.
B. Methadone is classified as a C-II (Schedule II) controlled substance because it has a high potential for abuse, but it also has accepted medical uses, such as for opioid withdrawal management.
C. C-I drugs are considered to have no accepted medical use and a high potential for abuse (e.g., heroin, LSD). Methadone is not classified as a C-I drug.
D. C-III drugs have a moderate potential for abuse and are generally used for medications like anabolic steroids or some barbiturates, but methadone is not classified under C-III.
Correct Answer is C
Explanation
a) Noncompliance due to cost might be a concern for some patients, but it does not directly relate to the sedative effects of the drug.
b) Deficient knowledge could be relevant if the patient is unaware of the potential sedative effects, but the immediate concern is more focused on the potential for injury due to sedation.
c) Risk for injury is the priority nursing diagnosis in this scenario because sedation can impair the patient's ability to perform tasks safely, increasing the risk for falls or other injuries. This is particularly important for elderly patients, who are more vulnerable to the sedative effects of medications.
d) Ineffective health maintenance refers to issues with ongoing health practices, but it is less directly related to the immediate risk posed by the sedative effects of the medication.
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