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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
This statement is incorrect. Sulfonamides should be taken for the full time of treatment, even if the patient begins to feel better after a few days. If the medication is stopped too soon, the symptoms may return.
Choice B rationale:
This statement is correct. Sulfonamides can cause increased photosensitivity, which means the skin can be more sensitive to the sun and burn more easily. Therefore, patients should be educated to use sunscreen and protective clothing with sun exposure.
Choice C rationale:
This statement is correct. Sulfonamides are best taken with a full glass (8 ounces) of water. Several additional glasses of water should be taken every day, unless otherwise directed by the doctor. Drinking extra water will help to prevent some unwanted effects of sulfonamides.
Choice D rationale:
This statement is incorrect. Restricting daily fluid intake to 1000ml per day while on sulfonamides could increase the risk of crystalluria that can cause kidney stones or decreased kidney function. Therefore, patients should increase their water intake while taking these medications.
Correct Answer is C
Explanation
Choice A rationale:
The client stating, “I haven’t had anything to eat or drink since last night” is not a cause for concern. This is because patients are often advised to fast before undergoing certain medical procedures or tests, including an intravenous pyelogram (IVP).
Fasting helps to ensure that the test results are accurate and not influenced by recent food or drink consumption.
Choice B rationale:
The client expressing that “The last time I voided it was painful” could be related to their recurrent kidney stones. Kidney stones can cause discomfort or pain during urination. However, this statement does not necessarily require additional data collection in the context of an IVP. The pain could be a symptom of the kidney stones rather than a contraindication for the IVP1.
Choice C rationale:
The statement “I took my metformin before breakfast” is of concern. Metformin is a medication used to treat type 2 diabetes. It is important for the nurse to collect additional data about this statement because metformin can potentially interact with the iodine-based contrast dye used in an IVP. This interaction can increase the risk of lactic acidosis, a serious and potentially lifethreatening condition. Therefore, patients are often advised to stop taking metformin before and for a couple of days after having an IVP12. Choice D rationale:
The client mentioning, “I took a laxative yesterday” is not necessarily alarming. Laxatives are often used before an IVP to clear the bowels, which helps to ensure clear images during the procedure. Therefore, this statement does not require additional data collection in the context of an IVP1.
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