Which of the following best describes the "right documentation" of medication administration?
Document the medication before giving it.
Document only if the patient refuses.
Document the medication only if it caused side effects.
Document after the medication is administered.
The Correct Answer is D
A. Document the medication before giving it: Documenting before administration risks recording a medication that may not actually be given, leading to errors and inaccurate medical records.
B. Document only if the patient refuses: Documentation is required for all administered medications, not just when a patient refuses, to ensure accurate tracking, legal compliance, and continuity of care.
C. Document the medication only if it caused side effects: Side effects must be documented, but documentation of the administration itself is always necessary, regardless of the patient’s reaction, to maintain an accurate record.
D. Document after the medication is administered: Recording the medication after administration ensures that the entry reflects an actual event, confirming that the patient received the correct drug, dose, route, and time. This practice aligns with safe and legal nursing standards.
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Related Questions
Correct Answer is C
Explanation
A. in: The abbreviation “in” is commonly used to indicate inches and is widely recognized in clinical and household contexts. It does not pose a risk of misinterpretation in medication administration.
B. tsp: “tsp” stands for teaspoon and is a standard, accepted abbreviation for liquid measurements. It is safe for use when teaching patients or administering medications.
C. OZS: The correct abbreviation for ounces is “oz,” not “OZS.” Using “OZS” can lead to misinterpretation and dosing errors, making this abbreviation unsafe and in need of clarification.
D. tbsp: “tbsp” stands for tablespoon and is an accepted and widely understood abbreviation. It is standard for measuring liquid medications and does not require questioning.
Correct Answer is D
Explanation
A. HEPARIN contains tall man lettering: Tall man lettering is used to differentiate look-alike or sound-alike drug names, usually by capitalizing parts of the name. In this case, the label uses all capital letters for the drug name, which is standard labeling, not tall man lettering.
B. HEPARIN is the brand name of the drug: HEPARIN is the generic name of the medication. Brand names are typically capitalized and trademarked, whereas this label shows the generic drug name.
C. The vial must be discarded after the first dose regardless of the dose administered: The label specifies it is a 1-mL multi-dose vial. Multi-dose vials are intended for multiple uses, so discarding after the first dose is unnecessary unless sterility is compromised.
D. The vial can be used for the administration of multiple doses: The label clearly states “1-mL Multi-Dose Vial,” indicating that it is designed for multiple administrations. Proper aseptic technique must be used for each withdrawal to maintain sterility.
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