Chapter 1: The Nursing Process and Drug Therapy

The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled does was due. What type of problem does this represent? A. "Right time" problem B. "Right dose" problem C. "Right route" problem D. "Right medication" problem

A. "Right time" problem

Which information is of highest priority when obtaining a pharmacologic history from a patient? A. Allergies B. Use of over-the-counter medications C. Home remedy use D. Alcohol intake

A. Allergies The key to this question is the phrase "of highest priority." Identification of allergies is of highest priority. Although the other answers are important, giving a patient a medication to which he or she is allergic can be life-threatening

While the nurse is taking an admission history, the patient reports having a previous allergic reaction to penicillins. What will the nurse document as part of the patient's allergic reaction response to penicillins? A. Hives B. Dry eyes C. Frequent urination D. Constipation

A. Hives The hives reported by the patient are the only physiological symptom associated with a true allergic reaction. The others are possible side effects for many medications but do not demonstrate a true reaction from the drug to document in the chart.

Which activity best reflects the implementation phase of the nursing process for a patient who is newly diagnosed with type hypertension? A. Providing education on keeping a journal of blood pressure readings B. Setting goals and outcome criteria with the patient's input C. Recording a drug history regarding over-the-counter medications used at home D. Formulating nursing diagnoses regarding knowledge deficit related to new treatment regimen

A. Providing education on keeping a journal of blood pressure readings Education is an intervention that occurs during the implementation phase. Setting goals and outcomes reflects the Planning phase. Recording a drug history reflects the Assessment phase. Formulating nursing diagnoses reflects analysis of data as part of Planning.

Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 as the last phase. 1. Evaluation 2. Nursing Diagnoses 3. Assessment 4. Implementation 5. Planning

Assessment Nursing Diagnoses Planning Implementation Evaluation A.D.P.I.E. The nursing process is an ongoing process that begins with assessing and continues with diagnosing, planning, implementing, and evaluating.

The nurse has been monitoring a patient's progress on a new drug regimen since the first dose and documenting signs of possible adverse effects. This example illustrates which phase of the nursing process? A. Planning B. Evaluation C. Implementation D. Nursing diagnosis

B. Evaluation Monitoring the patient's progress is part of the evaluation phase. Planning, Implementation, and Nursing Diagnosis are not illustrated by this example.

The nurse has been monitoring a patient's progress on a new drug regimen since the first dose and documenting the patient's therapeutic response to the medication. This example illustrates which phase of the nursing process? A. Planning B. Evaluation C. Implementation D. Nursing diagnosis

B. Evaluation Monitoring the patient's progress is part of the evaluation phase. Planning, Implementation, and Nursing Diagnosis are not illustrated by this example.

The nurse should check a medication how many times before administration of a medication under the "right drug" part of the Six Rights? A. One time B. Three times C. Five times D. Depends on the drug being administered

B. Three times The nurse should check the medication three times and confirm each time that the medication is the right drug before to administration of the medication.

During the implementation phase of the nursing process, which action will the nurse perform when administering medications? A. Switch the route of administration based on drug availability. B. Call the patient by name when entering the room to verify the drug is for the right person. C. Check the patient's armband before administering the medication. D. Prepare medications for all patients first, then administer by room to manage time appropriately.

C. Check the patient's armband before administering the medication. Checking the patient's armband is the most accurate method of determining identity. All the other answers leave room for error.

For which activity is the nurse responsible during the evaluation phase of drug administration? A. Preparing and administering prescribed medications safely B. Planning measurable outcomes for the patient related to drug therapy C. Monitoring the patient continuously for therapeutic as well as adverse effects D. Gathering data in a drug and dietary history

C. Monitoring the patient continuously for therapeutic as well as adverse effects Ongoing monitoring of the patient evaluates the effect of the drug on the patient. All the other answers refer to different steps in the nursing process.

The nurse is performing an assessment of a newly admitted patient. Which is an example of subjective data? A. Blood pressure 158/96 B. Weight 255 pounds C. The patient reports that he uses the herbal product ginkgo. D. The patient's laboratory work includes a complete blood count and urunalysis

C. The patient reports that he uses the herbal product ginkgo. Subjective information is a patient's account of information that can not be physically seen or measured.

The nursing process is important as a well-established, research-supported framework for professional nursing practice. Which is the correct order for the steps of the nursing process? A. Evaluation, Planning, Diagnoses, Assessment, Implementation B. Planning, Assessment, Diagnoses, Implementation, Evaluation C. Diagnoses, Assessment, Planning, Evaluation, Implementation D. Assessment, Diagnoses, Planning, Implementation, Evaluation

D. Assessment, Diagnoses, Planning, Implementation, Evaluation A.D.P.I.E The typical organization for the nurse process is assessment, nursing diagnoses, planning, implementation, and evaluation.

The nurse notes that a medication was scheduled to be administered at 0900. A medication error has occurred if the medication was administered at which time? A. 0800 B. 0830 C. 0900 D. 0930

A. 0800 Medications must be given no more than 30 minutes before or after the actual time specified in the prescriber's orders. If the medication was administered at 0800 but had been scheduled for 0900, then a medication error has occurred.

The nurse has an order for administering a medication to the patient. Which providers have legal authority to prescribe medications for patients? (Select all that apply.) A. Physician B. Physical therapist C. Pharmacist D. Dentist E. Physician assistant F. Nurse practitioner

A. Physician D. Dentist E. Physician assistant F. Nurse practitioner The providers who have privileges to prescribe medications for patients include physicians, dentist, physician assistants, and nurse practitioners. The exact medications that can be prescribed by non-physicians may vary from state to state as well as the type of agreement for prescriptive authority.

Which activity best reflects the implementation phase of the nursing process for a patient who is newly diagnosed with type 1 diabetes mellitus? A. Providing education regarding self-injection technique B. Setting goals and outcome criteria with the patient's input C. Recording a drug history regarding over-the-counter medications used at home D. Formulating nursing diagnoses regarding knowledge deficit related to new treatment regimen

A. Providing education regarding self-injection technique Education is an intervention that occurs during the implementation phase. Setting goals and outcomes reflects the Planning phase. Recording a drug history reflects the Assessment phase. Formulating nursing diagnoses reflects analysis of data as part of Planning.

When giving medications, the nurse will follow the rights of medication administration, which include what rights? Select all that apply. A. Right drug B. Right route C. Right dose D. Right diagnosis E. Right time F. Right patient G. Right documentation

A. Right drug B. Right route C. Right dose E. Right time F. Right patient G. Right documentation The Six Rights of Medication Administration must always include the right drug, the right route, the right dose, the right time, the right patient, and the right documentation. *Right Reason

A patient is to receive oral digoxin (Lanoxin) daily; however, because he is unable to swallow, he cannot take it orally, as ordered. What type of problem does this represent? A. "Right time" problem B. "Right dose" problem C. "Right route" problem D. "Right medication" problem

C. "Right route" problem Because the patient cannot swallow, the prescriber must adjust the ordered route. "Time" is not correct because the ordered frequency has not changed. "Dose" is not correct because the dose is not related to inability to swallow. "Medication" is not correct because the medication ordered will not change, just the route.

The medication order reads, "Give ondansetron 24 mg, 30 minutes before beginning chemotherapy to prevent nausea." The nurse notes that the route is missing from the order. What is the nurse's best action? A. Giving the medication intravenously because it is for nausea prevention B. Giving the medication orally because the tablets are available in 24 mg doses C. Contacting the prescriber to clarify the route of the medication ordered D. Holding the medication until the prescriber returns to clarify the order

C. Contacting the prescriber to clarify the route of the medication ordered A complete medication order includes the route of administration. If a medication order does not include the route, the nurse must ask the prescriber to clarify it. The other options are not correct actions.

When the nurse considers the timing of a drug dose, which of the factor is appropriate to consider when deciding when to give a drug? A. The patient's ability to swallow B. The patient's weight C. The patient's last meal D. The patient's allergies

C. The patient's last meal The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may be affected by the timing of the last meal. The patient's ability to swallow, weight, and allergies are not factors to consider regarding the timing of the drug's administration.

The nurse is writing a nursing diagnosis for a plan of care for a patient who has been newly diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing diagnosis? A. Anxiety B. Anxiety related to new drug therapy C. Anxiety related to feelings about drug therapy as evidenced by statements such as "I'm upset about having to give myself shots" D. Anxiety related to new drug therapy as evidenced by statements such as "I'm upset about having to give myself shots"

D. Anxiety related to new drug therapy as evidenced by statements such as "I'm upset about having to give myself shots" Formulation of nursing diagnoses is usually a three-step process. "Anxiety" is missing the "related to" and "as evidenced by" portions. "Anxiety related to new drug therapy" is missing the "as evidenced by" portion of defining characteristics. The statement beginning "Anxiety related to anxious feelings" is not correct because the "related to" section is simply a restatement of the problem "anxiety," not a separate factor related to the response.

The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus. Which statement best illustrates an outcome criterion for this patient? A. The patient will follow instructions. B. The patient will not experience complications. C. The patient will adhere to the new insulin treatment regimen. D. The patient will demonstrate safe insulin self-administration technique.

D. The patient will demonstrate safe insulin self-administration technique. "Demonstrating safe insulin self-administration technique" is a specific and measurable outcome criterion. "Following instructions" and "not experiencing complications" are not specific criteria. "Adhering to new regimen" would be difficult to measure.

The nurse should include which information when evaluating the outcome after a patient's medication has been administered? A. Dose of medication administered B. Time medication administered C. Patient allergies to medications D. Therapeutic effect on patient

D. Therapeutic effect on patient The effect of the medication on the patient is part of the evaluation process after a medication is administered.