When administering a medication, the nurse's priority is to:
Follow the medication schedule strictly.
Ensure the patient takes the medication correctly.
Confirm the right medication, dose, route, and patient before administration.
Document after giving the medication.
The Correct Answer is C
Choice A rationale
While following the medication schedule strictly is a crucial part of medication administration, it is not the absolute priority. Administering a medication at the wrong time could potentially harm the patient if other checks are not performed first, highlighting that the core safety checks are the foremost priority.
Choice B rationale
Ensuring the patient takes the medication correctly is an important step in the process, but it follows the initial and more critical steps of verifying the medication and dose. If the incorrect drug is prepared or the wrong dose is calculated, the act of the patient taking it correctly becomes irrelevant and potentially dangerous.
Choice C rationale
The nurse's highest priority is to confirm the right medication, dose, route, and patient, as this practice, known as the "five rights," is the cornerstone of patient safety. This step minimizes the risk of administering the wrong drug, the wrong dose, or to the wrong patient, which could lead to severe adverse outcomes.
Choice D rationale
Documentation is a vital part of the medication administration process for legal and continuity of care purposes, but it must be done after the medication has been administered. Documenting before the action is completed can lead to errors and is not considered a safe practice, therefore it cannot be the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Abruptly stopping nitroglycerin is not the correct first action. The headache and dizziness are common side effects due to its vasodilatory action. Stopping the medication without assessment can leave the patient vulnerable to ongoing chest pain, and the provider needs to be aware of the patient’s hemodynamic response to the drug.
Choice B rationale
Giving an extra dose of nitroglycerin would exacerbate the patient's symptoms and could lead to a life-threatening drop in blood pressure. The severe headache and dizziness are signs of systemic vasodilation, and a further dose would intensify this effect, increasing the risk of severe hypotension and syncope.
Choice C rationale
Alcohol consumption is contraindicated with nitroglycerin as it can intensify the vasodilatory and hypotensive effects, worsening the dizziness and increasing the risk of a severe drop in blood pressure. The combination could lead to syncope, falls, and dangerously low blood pressure.
Choice D rationale
Nitroglycerin's primary mechanism is vasodilation, which can cause a drop in blood pressure. The patient's headache and dizziness are classic symptoms of hypotension. Assessing blood pressure provides crucial data for the healthcare provider to determine if the patient is experiencing a significant hypotensive event and whether the medication dose needs adjustment or discontinuation. A normal BP is (90/60 mmHg to 120/80 mmHg).
Correct Answer is C
Explanation
Choice A rationale
Valerian is a sedative herb used to treat insomnia and anxiety. It promotes sleep and has a calming effect on the central nervous system. Therefore, insomnia is the opposite of its intended therapeutic effect and would not be considered an adverse effect.
Choice B rationale
Valerian is not typically associated with causing jaundice or yellow skin. Yellow skin is a symptom of liver dysfunction, which is more commonly associated with certain other herbal supplements. While rare, liver injury is possible with valerian.
Choice C rationale
Valerian may affect blood clotting and can increase the risk of bleeding. This can manifest as bruising or an increased propensity for bleeding. Patients taking anticoagulants or antiplatelet drugs should be cautioned about this potential interaction.
Choice D rationale
Valerian is used as a sleep aid and sedative. It does not typically increase appetite. Increased appetite is more often associated with certain psychotropic medications or medical conditions, and it is not a known adverse effect of valerian.
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