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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a) The Physician's Desk Reference (PDR) is a valuable resource but is primarily designed for physicians. It contains drug manufacturer information but may lack nursing-specific details like patient education, nursing interventions, and administration guidelines.
b) A Nurse's Drug Guide/Handbook is the best resource for nurses because it includes essential nursing considerations such as patient education, side effects, contraindications, nursing interventions, and administration tips.
c) A drug package insert provides useful information but is not comprehensive and does not include nursing-specific recommendations. It primarily contains manufacturer-provided details on indications, dosing, and warnings.
d) Drug Facts and Comparisons is a resource primarily used by pharmacists for comparing medications rather than providing nursing-focused drug information.
Correct Answer is B
Explanation
A. Distribution refers to the movement of the drug from the bloodstream into tissues and organs, but it does not explain why only a portion of the medication reaches the tissues.
B. The first-pass effect occurs when an orally administered drug is metabolized by the liver before reaching systemic circulation. Aspirin, when taken orally, undergoes significant metabolism in the liver, reducing the amount of active drug available to exert its therapeutic effect. This explains why only a portion of the drug reaches the tissues.
C. Reduced absorption can limit drug availability, but aspirin is generally well absorbed in the gastrointestinal tract. The primary reason for reduced drug availability in this case is metabolism by the liver, not poor absorption.
D. Gastrointestinal circulation involves the enterohepatic recycling of some drugs, but it does not explain why only a portion of aspirin reaches systemic circulation. The first-pass effect is the primary factor.
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