Which of these is the correct way for a nurse to document medication administration?

Record the drugs given during the shift before the shift ends.

Record the drugs given by the client's pharmacy technician.

Record the drugs immediately after administration to clients.

Record the drugs given by any member of the client-care team.

Answer and Explanation

The Correct Answer is C

Choice A reason: Recording at shift’s end risks memory errors or omissions; delayed documentation compromises accuracy and legal accountability for controlled substances and patient care.

Choice B reason: Pharmacy technicians don’t administer drugs; nurses document their own actions, ensuring responsibility and precision in the medication administration record.

Choice C reason: Immediate recording post-administration ensures accuracy, timeliness, and compliance with standards; it reflects real-time events, reducing errors in patient care documentation.

Choice D reason: Recording others’ actions is inaccurate and unethical; nurses must document only their administrations, maintaining individual accountability and patient safety.

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Correct Answer is B

Explanation

Choice A reason: Crushing pills can alter drug efficacy and safety, especially for medications with controlled-release properties, making this inappropriate without specific provider instructions.

Choice B reason: Requesting a liquid form accommodates the patient’s physical limitations, maintaining therapeutic integrity and ensuring safe and effective medication administration.

Choice C reason: Introducing pills directly into the patient’s mouth risks aspiration and violates safe administration practices, emphasizing the need for alternative methods.

Choice D reason: If the patient struggles to hold the cup, self-administration becomes impractical. Assistance through appropriate alternative forms ensures compliance and safety.

A. Call the client's name. B. Ask the client to fully state name, and check the client's identification armband with the medication administration record (MAR). C. Ask the family or visitors the client's name. D. Check the client's name on the door or bed.

Correct Answer is B

Explanation

Choice A reason: Calling the name relies on response accuracy; confused or hearing-impaired patients may not answer correctly, risking misidentification and medication errors.

Choice B reason: Verbal confirmation plus armband verification against the MAR ensures identity via two identifiers, aligning with safety protocols to prevent administration errors scientifically.

Choice C reason: Family or visitors may misidentify due to stress or error; this lacks direct patient verification, increasing risk of giving medication to the wrong individual.

Choice D reason: Bed or door labels can be outdated or misplaced; this indirect method fails to confirm identity actively, heightening the chance of medication misadministration.

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Which of these is the correct way for a nurse to document medication administration?

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