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 D

Explanation

A. Deficient knowledge may be a concern, but the primary focus here is on the safety risk associated with the side effects of the medication, particularly dizziness and orthostatic hypotension, which increase the risk of falls or injury.

B. Ineffective health maintenance is not specific to the medication side effects and does not directly address the patient's safety risk due to the medication.

C. Readiness for enhanced knowledge is more appropriate when the patient is already familiar with their condition and medication and is ready to learn more. This is not the case here, as the focus is on preventing harm from side effects.

D. Risk for injury is the most appropriate nursing diagnosis. Dizziness and orthostatic hypotension increase the risk of falls, which can lead to injury, making this the most relevant concern in this scenario.

A. Drugs are tested on adults and safe doses for children are based on weights compared to adult weights. B. Drugs are deemed safe for children over time when repeated use proves effectiveness and safety. C. Drugs are tested for both efficacy and safety in children in order to be marketed for pediatric use. D. Drugs are tested on children in post-marketing studies and on a limited basis.

Correct Answer is C

Explanation

A. While pediatric doses are often weight-based, this does not fully account for differences in drug metabolism and effects in children. Pediatric drug safety requires specific testing beyond weight comparisons to adults.

B. Relying on repeated use over time to determine safety is not an evidence-based approach. Drug approval for pediatric use requires formal clinical trials to establish safety and efficacy.

C. The U.S. FDA and other regulatory agencies require that drugs intended for pediatric use undergo clinical trials specifically designed to assess safety, efficacy, and appropriate dosing in children. This ensures that medications are appropriately tested before being marketed for pediatric patients.

D. While some post-marketing studies may include children, initial approval for pediatric use requires pre-market clinical testing. Relying solely on post-marketing studies does not ensure comprehensive safety data before widespread pediatric use.

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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 D

Explanation

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Correct Answer is C

Explanation

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