Ch 1 - The Nursing Process and Drug Therapy

The nurse would check a medication how many times before administering it?: - 1 times - 5 times - 3 times - It varies, depending on the drug being administered

3 times; Rationale: The nurse would check the medication three times and confirm each time that the medication is the right drug before administering the medication. Medication checks do not vary based on the drug being administered. One time is not sufficient to ensure correct medication information. Five times is not necessary. (p. 6)

The prescriber orders that a medication be given at 9:00 p.m. Which military time would the nurse document in the patient chart for this medication?: - 1500 - 1800 - 2100 - 2400

2100; Rationale: Most health care agencies use military time for documenting medicine administration. The military time corresponding to 9:00 p.m. is 2100. The military time of 1500 corresponds to 3:00 p.m.; 1800 corresponds to 6:00 p.m., and 2400 corresponds to 12:00 a.m. (p. 7)

Which providers have legal authority to prescribe medications for patients? Select all that apply: - Dentist - Physician - Pharmacist - Physical Therapist - Nurse Practitioner - Physician Assistant

- Dentist - Physician - Nurse Practitioner - Physician Assistant; Rationale: The providers who have privileges to prescribe medications for patients include dentists, physicians, nurse practitioners, and physician assistants. The exact medications that can be prescribed by nonphysicians and the type of agreement for prescriptive authority may vary from state to state. (p. 4)

Within which time frame from when a prescription is written must a nurse administer a medication that is ordered "stat"?: - 1/2 hour - 1 hour - 2 hours - 3 hours

1/2 hour; Rationale: When medications are prescribed as "stat," the nurse must administer the dose within ½ hour of the time the prescription was written. Administering a medicine ordered to be given stat within 1, 2, or 3 hours are all incorrect because they exceed the ½ hour requirement. (p. 7)

Which action would the nurse take when reviewing a medication order for diazepam 5 mg once daily at 2100?: - Administer the medicine to the patient by mouth at 2100 - Administer the medicine to the patient intravenously at 2100 - Administer the medicine to the patient intramuscularly at 2100 - Administer the medicine after confirming the route with the provider

Administer the medicine after confirming the route with the provider; Rationale: It is important to clarify the route of administration for all medicines. If the route is not included in the prescription, it should never be assumed because this could result in patient harm. The nurse must always confirm the route before administering any medication. (P. 8)

Which is the correct order for the steps of the nursing process?: - Evaluation, planning, diagnoses, assessment, implementation - Planning, assessment, diagnoses, implementation, evaluation - Diagnoses, assessment, planning, evaluation, implementation - Assessment, diagnoses, planning, implementation, evaluation

Assessment, diagnoses, planning, implementation, evaluation; Rationale: The typical organization for the nursing process is assessment, nursing diagnoses, planning, implementation, and evaluation. (p. 2)

During the implementation phase of the nursing process, which action will the nurse perform when administering medications?: - Prepare medications for all patients, then administer - Decide the route of administration based on drug availability - Call the patient by name to verify the drug is for the right person - Check the patient's identification band before administering the medication

Check the patient's identification band before administering the medication; Rationale: Checking the patient's identification band is the most accurate method of determining identity. Patient medications should be prepared immediately before administering to a patient to help prevent medication errors; medications for multiple patients should not be prepared at once. The nurse does not change the route of administration. Calling the patient by name does not verify who the patient is. (p. 5)

Which action would the nurse take when unsure of the exact dosage of a prescribed medicine?: - Give the standard dosage of the medication - Look for the dosage on the label of the medicine - Contact the health care provider for dosage clarification - Ask a colleague for the common dosage of the medication

Contact the health care provider for dosage clarification; Rationale: If the nurse has any doubt about the prescription, he or she would call the health care prescriber for clarification. Clarification helps prevent medication errors. Giving the standard dose, looking for dosage on the label, and asking a colleague are all unsafe nursing practices. (p. 7)

Which information is essential for the nurse to assess when evaluating a medication order?: - Age of the patient - Sex of the patient - Occupation of the patient - Date of the medication order

Date of the medication order; Rationale: While evaluating the medication order, the following elements should be assessed: patient name; date of drug order; name of drug(s); drug dosage amount and frequency; route of administration, and prescriber's signature. This ensures accuracy of drug administration. The patient's age, sex, and occupation are not assessed during the evaluation of a medication order. (p. 4)

A patient reports decreased sensation in the left arm and a persistent headache that prevents sleep. The nurse observes that the patient's right eyelid is drooping. The patient's blood pressure is 140/80 mm Hg. The report from the computed tomography (CT) scan of the brain reveals a right middle cerebral artery hemorrhage. Which assessment information is classified as subjective data?: - Increased blood pressure - Drooping of the right eyelid - Decreased sensation in the left arm - Results of CT scan showing hemorrhage

Decreased sensation in the left arm; Rationale: Subjective data include any information that is reported by the patient. The patient reports loss of sensation in his left arm, so this is considered subjective data. Objective data include physical examination findings by a nurse or other health care professional, vital sign measurements, and reports from laboratory and diagnostic studies or procedures. Therefore increased muscle tone in the left upper and lower extremities, right eyelid drooping, increased blood pressure, and right middle cerebral artery hemorrhage identified on the CT scan are all considered objective data. (p. 3)

An experienced nurse is discussing the rights of medication administration with nursing students. The nurse teaches that completion of which "right" is essential as proof of completion of all other rights?: - Right dose - Right drug - Right route - Right documentation

Right documentation; Rationale: Right documentation is the essential "proof" that all is completed. If it is not documented, it is not completed! Right dose, right drug, and right route do not indicate completion of all of the rights. (p. 8)

A patient with hypothyroidism is prescribed "Levothyroxine 50 mcg PO." Which information is missing from the prescription?: - Total dose - Route of administration - Number of days of treatment - Frequency of drug administration

Frequency of drug administration; Rationale: A prescription should contain seven elements: the patient name; the date the order was written; the name of the drug; the dose; the dosage frequency; the route of administration, and the practitioner's signature. A patient with hypothyroidism typically takes levothyroxine orally half an hour before food once daily in the morning. These details should be mentioned in the prescription for safe and effective treatment of the patient's condition. A prescription does not have information about adverse effects or any other drug information. Prescriptions do not contain information about contraindications. The patient should continue the treatment because hypothyroidism is a chronic disease; the number of days of treatment will not be on the prescription. (p. 7)

Which symptom is an example of an allergic reaction?: - Hives - Dry eyes - Constipation - Frequent urination

Hives; Rationale: Hives are the only physiologic symptom associated with an allergic reaction. The others are possible side effects of many medications but do not demonstrate symptoms of an allergic reaction. (p. 3)

When assigned to a maternity unit, which technique would the nurse use to identify the mother and child for safe administration of medication?: - Ask the mother to state the baby's name - Ask the mother if she can identify her newborn - Ask the mother and father both to identify the baby - Make certain the identification bracelets on the mother and baby have the same numbers.

Make certain the identification bracelets on the mother and baby have the same numbers; Rationale: The commonly used system to identify a new mother with her baby is for each to wear bracelets with matching identification numbers. The other statements are not accurate ways to identify the baby correctly as they all rely on the mother's report and not objective data such as the information provided on an identification bracelet. (p. 8)

Which action performed by the nurse is a method of data collection?: - Observing the patient - Explaining the illness to the patient - Changing the patient's wound dressing - Performing relevant diagnostic procedures

Observing the patient; Rationale: Detailed data collection is required for the proper assessment of the patient. The methods of data collection include interviewing the patient and caregivers, observing the patient, and performing a head-to-toe, detailed physical examination. Explaining the patient's illness to the patient is not an assessment method. Diagnostic procedures would be done only by specialists; nurses do not perform diagnostic procedures within their scope of practice. Changing the patient's wound dressing is a nursing procedure, not a method of data collection. (p. 3)

A patient reports chest pain, shortness of breath, and palpitations. The patient's electrocardiogram (ECG) indicates a rapid heart rate. The medical record indicates that the patient is allergic to penicillin. Which data is classified as objective data?: - Chest pain - Palpations - Shortness of breath - Rapid heart rate on ECG

Rapid heart rate of ECG; Rationale: The assessment phase of the nursing process consists of collecting data on the patient. The data elements collected may be subjective or objective. Subjective data are reported by the patient, whereas objective data are collected by the nurse using his or her sensory organs to obtain findings based on physical examination of the patient and review of reports from laboratory and diagnostic studies and procedures. The rapid heart rate identified on the ECG is an example of objective data. Chest pain, palpitations, and shortness of breath reported by the patient are examples of subjective data. (p. 3)

A health care provider writes a prescription for "gentamicin 100 mg every 8 hours." Which information about the drug is missing from the prescription?: - Dose - Route - Strength - Generic Name

Route; Rationale: The prescription does not indicate the route for administering the drug, so the nurse must contact the prescriber for this information. The drug name, dose, and frequency of administration are all included in the prescription. Therefore no clarification is necessary for these items. The strength of the drug is not required on the prescription. This determination is usually made by the pharmacist. (p. 8)

Which information should the nurse verify before administering acetaminophen to a pediatric patient?: - The patient's home address on the prescription - The manufacturer of the drug on the prescription - The signature of the patient's parent on the prescription - The name of the drug to be administered on the prescription

The name of the drug to be administered on the prescription; Rationale: Before administering a drug to a pediatric patient, the nurse verifies the name, dose, route, and frequency of the drug as well as the name of the patient and the prescriber's signature on the prescription. It is not necessary for the nurse to verify the parent signature, drug manufacturer, or patient home address because these items are not included on the prescription. (p. 4)

The nurse is assessing a patient who reports abdominal pain. Which subjective data should the nurse document?: - The abdominal radiograph is normal - Bowel sounds are heard on auscultation - No abnormality is detected on palpation - The patient reports abdominal pain since yesterday

The patient reports abdominal pain since yesterday; Rationale: Subjective data include the information that the patient shares. The patient stating abdominal pain is present constitutes subjective data. Objective data are those that the nurse observes. A normal abdominal radiograph, findings on abdominal palpation, and abdominal auscultation findings are all objective data. (p. 3)

Which information is essential for the nurse to evaluate after a medication is administered to a patient?: - Patient allergies to medications - Therapeutic effect on the patient - Dose of medication administered - Time the medication is to be administered

Therapeutic effect on the patient; Rationale: The effect of the medication on the patient is part of the evaluation process after a medication is administered. Patient allergies, dose of the medication, and the time the medication is to be administered are all components of verifying medication orders prior to administration. (p. 5)