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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Administering an expired medication is unsafe. Even if the medication appears unchanged, its potency, stability, and effectiveness may be compromised.

B. There is no medication error in this scenario, as the nurse has not yet administered the drug. However, the pharmacy should be notified so that a replacement can be provided.

C. The appropriate action is to return the expired medication to the pharmacy for a replacement. Medications should not be administered if they are past their expiration date, as this can affect efficacy and patient safety.

D. Verifying the right patient is part of safe medication administration, but it does not address the issue of the expired medication. The correct response is to obtain a non-expired dose from the pharmacy.

A. Establish the identity of the client B. Document the administration of the medication C. Recheck the medication label D. Obtain orange juice for the client to take with the medication

Correct Answer is A

Explanation

a. The first priority when administering medication is to ensure the right patient is receiving the correct drug. This follows the "rights" of medication administration, which include right patient, right drug, right dose, right route, and right time. Identifying the patient prevents medication errors.

b. Documentation is essential but should occur after administering the medication, not before confirming the correct patient and drug.

c. Rechecking the medication label is important, but it should be done before reaching the patient’s bedside. Once at the bedside, patient identification takes priority.

d. Obtaining orange juice may be necessary if the medication requires it, but ensuring the right patient receives the correct medication is the most critical initial step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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