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
Explanation
Choice A rationale:
The statement “The intravenous medication will have delayed absorption into the body’s tissues” is incorrect. Intravenous (IV) therapy is administering fluids directly into a vein. It benefits treatment by enabling water, medication, blood, or nutrients to access the body faster through the circulatory system. This bypasses the gastric system so the body can take on more fluids quickly. Therefore, the absorption of intravenous medication into the body’s tissues is not delayed but rather immediate.
Choice B rationale:
The statement “The action of the medication will begin sooner when given intravenously” is correct. Administering a medication intravenously eliminates the process of drug absorption and breakdown by directly depositing it into the blood. This results in the immediate elevation of serum levels and high concentration in vital organs, such as the heart, brain, and kidneys. Therefore, the action of the medication begins sooner when given intravenously.
Choice C rationale:
The statement “The medication will cause fewer adverse effects when given intravenously” is not necessarily true. While some medications might cause fewer adverse effects when given intravenously, this is not a general rule for all medications. The adverse effects of a medication depend on various factors including the type of medication, the dose, the patient’s health condition, and more.
Choice D rationale:
The statement “There is a lower chance of allergic reactions when drugs are given intravenously” is not necessarily true. The chance of allergic reactions depends on various factors including the type of drug, the patient’s immune response, previous exposure to the drug, and more. It’s not related to the route of administration.
Correct Answer is C
Explanation
Choice A rationale:
Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.
Choice B rationale:
Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:
This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.
Choice D rationale:
While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.
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