Which action should be implemented next when a patient states they are allergic to the medication the nurse is ready to administer?.
Give the medication as ordered and record the patient's statements in the nurse's notes.
Withhold the medication and check the drug insert for information on reactions to the drug.
Withhold the medication and notify the prescriber of the situation.
Give the medication and monitor the patient at regular intervals for adverse effects.
The Correct Answer is C
Choice A rationale:
Giving the medication as ordered despite the patient’s stated allergy could lead to a severe allergic reaction.
Choice B rationale:
While checking the drug insert for information on reactions to the drug is important, the immediate action should be to withhold the medication.
Choice C rationale:
Withholding the medication and notifying the prescriber of the situation is the safest course of action when a patient states they are allergic to the medication.
Choice D rationale:
Giving the medication and monitoring the patient for adverse effects is not safe if the patient has stated they are allergic to the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A decrease in blood pressure is a common side effect when a medication increases urine output, as the reduction in fluid volume can lead to lower blood pressure.
Choice B rationale:
While a decrease in blood pressure might be desired in certain conditions (like hypertension), in this context it is a side effect, not the primary desired effect.
Choice C rationale:
The therapeutic effect of the medication in this case is to increase urine output, not to decrease blood pressure.
Correct Answer is D
Explanation
Choice A rationale:
While a clinical care pathway can guide the treatment plan, it is not specifically designed to develop a detailed plan for a patient in critical condition.
Choice B rationale:
A clinical care pathway is not specifically designed as a communication tool for nurses, but for all healthcare professionals involved in a patient’s care.
Choice C rationale:
A clinical care pathway does not document the plan for admission, but rather the standardized care plan for a specific condition.
Choice D rationale:
A clinical care pathway is indeed a standardized care plan derived from “best practice” patterns.
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