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The medication order reads, 'Give ondansetron 4 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. Give the medication intravenously because the patient might vomit.
- B. Give the medication orally because the tablets are available in 4-mg doses.
- C. Contact the prescriber to clarify the route of the medication ordered.
- D. Hold the medication until the prescriber returns to make rounds.
Correct Answer: C
Rationale: 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 intravenous and oral routes are not interchangeable. Holding the medication until the prescriber returns would mean that the patient would not receive a needed medication.
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The nurse is developing a human needs statement for a patient who has a new diagnosis of heart failure. Identification of human needs statements occur with which of these activities?
- A. Collection of patient data
- B. Administering interventions
- C. Deciding on patient outcomes
- D. Documenting the patient's behavior
Correct Answer: A
Rationale: Identification of human needs occurs with the collection of patient data.
The patient is to receive oral guafenesin twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled dose was due. What type of problem does this represent?
- A. Right time
- B. Right dose
- C. Right route
- D. Right medication
Correct Answer: A
Rationale: Right time' is correct because the medication was given more than 30 minutes after the scheduled dose was due. 'Dose' is incorrect because the dose is not related to the time the medication administration is scheduled. 'Route' is incorrect because the route is not affected. 'Medication' is incorrect because the medication ordered will not change.
The nurse has been monitoring the patient's progress on a new drug regimen since the first dose and documenting the patient's therapeutic response to the medication. Which phase of the nursing process do these actions illustrate?
- A. Human needs statement
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: Monitoring the patient's progress, including the patient's response to the medication, is part of the evaluation phase. Planning, implementation, and human needs statement are not illustrated by this example.
When the nurse considers the timing of a drug dose, which factor is appropriate to consider when deciding when to give a drug?
- A. The patient's ability to swallow
- B. The patient's height
- C. The patient's last meal
- D. The patient's allergies
Correct Answer: C
Rationale: 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, height, and allergies are not factors to consider regarding the timing of the drug's administration.
The nurse is assigned to a patient who is newly diagnosed with type I 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 correct blood glucose testing technique.
Correct Answer: D
Rationale: Demonstrating correct blood glucose testing 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.