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Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed with 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 human needs statements regarding deficient knowledge related to the new treatment regimen
Correct Answer: A
Rationale: 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 human needs statements reflects analysis of data as part of planning.
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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.
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 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 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.
When giving medications, the nurse will follow the rights of medication administration. The rights include the right documentation, the right reason, the right response, and the patient's right to refuse. Which of these are additional rights? (Select all that apply.)
- A. Right drug
- B. Right route
- C. Right dose
- D. Right diagnosis
- E. Right time
- F. Right patient
Correct Answer: A,B,C,E,F
Rationale: Additional rights of medication administration must always include the right drug, right dose, right time, right route, and right patient. The right diagnosis is incorrect.