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 B
Explanation
Choice A rationale
Lithium is a mood stabilizer primarily used in the treatment of bipolar disorder. Its therapeutic and toxic effects are not directly related to blood sugar regulation. While some antipsychotics can impact glucose metabolism, lithium's mechanism of action does not involve insulin or glucagon pathways. Therefore, blood sugar assessment is not the most critical lab value prior to administration.
Choice B rationale
Lithium is a monovalent cation that competes with sodium for renal reabsorption. When sodium levels are low, the kidneys reabsorb more lithium to compensate, increasing the risk of lithium toxicity. Conversely, high sodium can increase lithium excretion. Therefore, assessing a patient's serum sodium level (normal range: 135-145 mEq/L) is crucial to prevent lithium accumulation and subsequent toxicity.
Choice C rationale
While urine osmolality can be affected by lithium's long-term effects on the kidneys, such as nephrogenic diabetes insipidus, it is not the most crucial parameter to assess before starting therapy. The primary and immediate risk is related to the competition between lithium and sodium for reabsorption, which directly influences serum lithium levels and the risk of toxicity, making sodium assessment paramount.
Choice D rationale
Hematocrit measures the proportion of red blood cells in the blood and is not directly influenced by lithium. While long-term lithium use can affect other blood cell lines, such as leukocytes, hematocrit is not a primary safety concern or a pre-administration requirement. The most critical lab value for lithium safety is its close relationship with sodium and renal function.
Correct Answer is B
Explanation
Choice A rationale
Beta-blockers are used in heart failure to reduce myocardial oxygen demand and improve left ventricular ejection fraction. However, they are not the primary choice for immediate reduction of preload and pulmonary congestion, which are more effectively addressed by medications that directly reduce fluid volume.
Choice B rationale
Diuretics, such as loop diuretics like furosemide, are commonly used in heart failure to reduce preload by increasing sodium and water excretion from the body. This reduction in intravascular volume decreases venous return to the heart, thereby lowering pulmonary congestion and relieving symptoms like dyspnea and edema.
Choice C rationale
ACE inhibitors (angiotensin-converting enzyme inhibitors) are foundational for long-term heart failure management. They reduce afterload and slow disease progression by inhibiting the renin-angiotensin-aldosterone system. While they have some effect on fluid balance, they are not as effective as diuretics for rapid preload reduction and symptom relief.
Choice D rationale
Calcium channel blockers are generally not recommended for systolic heart failure. While some can reduce afterload, most may have negative inotropic effects, which could worsen heart failure symptoms by weakening the heart's pumping action. Their use is limited in specific types of heart failure.
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