The nurse works in a medical/surgical unit and cares for a patient receiving digoxin and furosemide.
The nurse knows that if the patient reports which of the following, it must be assessed immediately?

This question tests clinical safety protocols during medication administration. It requires identifying the breach of standard documentation policies, which mandate that medications are recorded only after they have been administered to the patient, to prevent medical errors and ensure accurate, safe clinical record-keeping.

Choice A rationale

Verifying the medication against the prescription and the label is a fundamental step in the medication administration process. This action is essential for confirming the "right medication" and "right dose" to prevent dangerous medication errors and ensure patient safety.

Choice B rationale

Documentation must never occur before the medication is physically administered to the patient. Pre-documentation is a critical safety violation that creates a false record and increases the risk of error, such as omitting the dose or administering it to the wrong patient.

Choice C rationale

Scanning the bar codes on the patient's ID band and the medication label is a standard, evidence-based technological safety check. This process is designed to reduce human error by electronically verifying that the correct medication is given to the correct patient.

Choice D rationale

Checking the provider's orders and verifying doses in a reliable drug reference guide is a core competency for safe medication administration. This action demonstrates sound clinical judgment and adherence to safety practices by ensuring the dosage is appropriate before administering it to the patient.

This question focuses on the patient education requirements for thiazide diuretics. It requires identifying the physiological side effects of diuresis, specifically frequency and nocturia, and how to structure medication administration to maximize therapeutic adherence while maintaining the patient's comfort and sleep quality.

Choice A rationale

Monitoring the therapeutic effect of hydrochlorothiazide is best achieved through daily weight monitoring. Weekly measurements are insufficient to detect fluid retention or rapid weight changes, which are early indicators of potential heart failure or medication ineffectiveness in hypertensive patients.

Choice B rationale

Muscle pain is not an expected adverse effect of hydrochlorothiazide. It may indicate electrolyte disturbances, such as hypokalemia, which is a known risk of thiazide diuretics. Patients must report muscle pain so the nurse can assess serum potassium levels.

Choice C rationale

Hydrochlorothiazide increases urine production. Taking the medication early in the day prevents nocturia, which is the frequent need to urinate at night. This instruction significantly improves the patient's quality of life and adherence to the prescribed daily treatment plan.

Choice D rationale

Hydrochlorothiazide can be taken with or without food. Taking it with food is often recommended if the patient experiences minor gastrointestinal upset. There is no pharmacological or clinical requirement for this medication to be taken strictly on an empty stomach.