When given a scheduled morning medication, the patient states, “I haven’t seen that pill before.

Are you sure it’s correct?” The nurse checks the medication administration record and verifies that it is listed.

Which is the nurse’s best response?

“Go ahead and take it and then I’ll check with your doctor about it.”

“It wouldn’t be listed here if it were not ordered for you.”

“Let me check on the order first before you take it.”

“It’s listed here on the medication sheet, so you should take it.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

This choice suggests that the nurse is advising the patient to take the medication first and then check with the doctor. This is not a safe practice. The nurse should always verify any doubts or concerns before administering the medication. Administering an unfamiliar medication can lead to adverse effects if it turns out to be incorrect.

Choice B rationale:

This choice implies that if a medication is listed on the medication administration record (MAR), it must be correct. However, errors can occur when transcribing medication orders onto the MAR. Therefore, it’s crucial for the nurse to verify any concerns or doubts before administering the medication.

Choice C rationale:

This is the correct choice. If a patient expresses concern about a medication, the nurse should always check the order before administering it. This is a fundamental aspect of patient safety and medication administration. It ensures that the right patient receives the right medication at the right dose via the right route at the right time.

Choice D rationale:

This choice suggests that because the medication is listed on the medication sheet, the patient should take it. However, this does not address the patient’s concern about the unfamiliar medication. It’s important for the nurse to validate the patient’s concern and verify the medication order before administration.

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Correct Answer is C

Explanation

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

A. “We’ll get you a prescription. B. As long as you start treatment within the next 24 hours, the drug should be effective.” C. “We will need to do a blood test to verify that you actually have the flu.” D. “Drug therapy should be started within 2 days of symptom onset, not 4 days.”

Correct Answer is C

Explanation

Choice A rationale:

This choice is incorrect. While it’s true that antiviral drugs can be effective in treating the flu, they’re most effective when started within 48 hours of symptom onset. Starting treatment after 4 days may not provide the same benefits.

Choice B rationale:

This choice is incorrect. While a blood test can confirm the presence of the flu virus, it’s not typically necessary to diagnose the flu. Diagnosis is usually based on symptoms and the fact that the flu is widespread in the community.

Choice C rationale:

This choice is correct. Antiviral drugs are most effective when started within 2 days of symptom onset. After this time, the benefits of these drugs decrease. Therefore, starting treatment 4 days after symptoms begin may not significantly reduce the duration or severity of symptoms.

Choice D rationale:

This choice is incorrect. While it’s true that getting a flu vaccine is important, it’s not the best response in this situation. The flu vaccine won’t treat current illness. It’s designed to prevent future infections. In this case, the individual is already sick, so a booster vaccination wouldn’t be the most effective course of action.

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When given a scheduled morning medication, the patient states, “I haven’t seen that pill before. Are you sure it’s correct?” The nurse checks the medication administration record and verifies that it is listed. Which is the nurse’s best response?

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Naxlex Comprehensive Predictor Exams

The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

Correct Answer is C

Explanation

A young adult calls the clinic to ask for a prescription for a new flu drug. He says he has had the flu for almost 4 days and just heard about a drug that can reduce the symptoms. What is the nurse’s best response to his request?

Correct Answer is C

Explanation

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Which of the following medications is typically prescribed for the treatment of hyperthyroidism?

When given a scheduled morning medication, the patient states, “I haven’t seen that pill before.

Are you sure it’s correct?” The nurse checks the medication administration record and verifies that it is listed.

Which is the nurse’s best response?