The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which phase of the nursing process?

Assessment

Evaluation

Implementation

Planning

Answer and Explanation

The Correct Answer is A

A. Assessment is the first phase of the nursing process, during which the nurse gathers relevant patient data, such as allergies and lab values, to ensure safe medication administration. This step helps identify potential risks and contraindications.

B. Evaluation occurs after the medication has been administered and involves assessing the patient's response to the drug. In this case, the nurse is reviewing information before administration, making evaluation an incorrect choice.

C. Implementation refers to carrying out the nursing interventions, such as actually administering the medication. Since the nurse is still reviewing data, this step has not yet been reached.

D. Planning involves setting goals and determining appropriate interventions, but it does not include the direct collection of patient data. Reviewing lab values and allergies falls under the assessment phase.

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Correct Answer is C

Explanation

a) Clarifying the order with the charge nurse is not the correct action. The charge nurse may not be able to clarify medication orders and is not the primary contact for this issue.

b) Diluting and administering the medication by gastrostomy tube (GT) is inappropriate because the medication is ordered to be taken p.o. (by mouth), not via the tube.

c) Clarifying the order with the healthcare provider is the most appropriate step. A p.o. order is typically for oral administration, but the client has a gastrotomy tube. The nurse should clarify with the provider whether the medication can be crushed and administered via the tube or if a different route or medication form is necessary.

d) Administering the medication p.o. as ordered would not be appropriate if the client is unable to take oral medications. The nurse should verify the appropriate route of administration based on the patient's condition.

A. Administer the medication and observe for adequate drug effects. B. Notify the pharmacist and provider of a medication error. C. Return the medication to the pharmacy to be replaced. D. Verify the right patient and administer the medication.

Correct Answer is C

Explanation

A. Administering an expired medication is unsafe. Even if the medication appears unchanged, its potency, stability, and effectiveness may be compromised.

B. There is no medication error in this scenario, as the nurse has not yet administered the drug. However, the pharmacy should be notified so that a replacement can be provided.

C. The appropriate action is to return the expired medication to the pharmacy for a replacement. Medications should not be administered if they are past their expiration date, as this can affect efficacy and patient safety.

D. Verifying the right patient is part of safe medication administration, but it does not address the issue of the expired medication. The correct response is to obtain a non-expired dose from the pharmacy.

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The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a gastrotomy tube in place. The health care provider ordered the medication p.o. Which action would be appropriate for the nurse to take?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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