Which Example Reflects Effective Documentation of Medication Administration by a Nurse

1. Which example reflects effective documentation of medication administration by a nurse? A. Comparing the written order with the medication administration record (MAR) three times B. Providing patient education regarding a medication C. Obtaining a BP before giving a blood pressure medication D. Including the location of an injection site on the MAR Rationale: Including the location of an injection is required when documenting the administration of injected medication. Comparing the written order with the MAR helps the nurse ensure that the medication order has been correctly transcribed into the dispensing system; however, this activity occurs before the documentation of medication administration. Although providing patient education is appropriate and should be included in patient documentation, this activity does not specifically address documentation of medication administration. Obtaining pre-assessments is important, but the nurse would do so before documenting medication administration. 2. What is the best way for the nurse to ensure that a patient receives the correct dose of a medication? A. Compare the prescriber’s order with the MAR before dispensing the medication. B. Ask the patient if he would like a larger dose of pain medication. C. Assess the patient’s ability to swallow oral medications without difficulty. D. Check the name of the medication three times against the MAR. Rationale: Reconciling the order with the MAR at the point of delivery ensures that the correct dose is selected. Assessing the effectiveness of pain medication is important, but the patient cannot increase the amount of medication he receives. Although it is appropriate to assess swallowing ability, doing so does not ensure the correct medication dose is give. Checking the name of the medication is required, but it will not ensure that the dose is correct. Medications come in a variety of strengths, and name and dose must be checked three times. 3. Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in documenting medication administration? A. “Make a note that the patient just received her PM dose of pain medication.” B. “Let me know if the patient says her nausea is getting worse.” C. “Can you check the MAR and see when this patient had her pain medication last?” D. “Ask the patient if I need to get another order from the provider.” Rationale: The nurse may delegate to NAP the task of reporting a patient’s symptoms. Documentation of medication administration may not be delegated to NAP. Reviewing medication documentation cannot be delegated to NAP. Neither the patient nor the NAP is responsible for making this clinical judgment. The skill of patient assessment is a nursing responsibility. 4. The patient refuses a scheduled dose of an antibiotic, saying that the medication makes him feel nauseated. What it the nurse’s best response? A. Inform the patient why the medication is necessary. B. Notify the prescriber of the patient’s reason for refusing the medication. C. Offer to administer the medication with the patient’s favorite snack food. D. Note the patient’s refusal in the MAR. Rationale: The provider must treat the infectious process for which the antibiotic was ordered. The provider may, for example, offer the patient an agent to alleviate the nausea associated with the medication or order a different agent that produces less nausea, such as an extended-release antibiotic. Informing the patient that the medication is necessary does not alleviate the nausea he feels when he takes it. Offering to administer the medication with the patient’s favorite snack food might not alleviate the patient’s nausea, in which case the patient is unlikely to be persuaded by this offer a second time. In addition, some antibiotics must be taken on an empty stomach. Noting the patient’s refusal in the MAR is appropriate, but the nurse must also notify the provider so that the infectious process for which the antibiotic was ordered can be treated. 5. While reviewing a new medication order, the nurse notes that the frequency of administration has been omitted. What is the nurse’s best response? A. Immediately contact the prescriber to complete the order. B. Refer to a current drug book for the most commonly prescribed dosage. C. Call the pharmacy to determine the frequency. D. Ask a registered nurse who is familiar with the prescriber to identify the usual frequency ordered. Rationale: The prescriber is required to include all pertinent information on the prescription. Referring to a current drug book is not an appropriate means of addressing an omission in a medication order. Calling the pharmacy to determine the frequency is not an appropriate means of addressing an omission in a medication order. Asking another nurse is not an appropriate means of addressing an omission in a medication order. 1. Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? A. Assess for the presence of external hemorrhoids. B. Provide assistance to the bathroom for expulsion of fluid and stool. C. Document the patient’s physical response to the enema. D. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes. Rationale: Assisting an older adult to the bathroom helps ensure the patient’s safety because it may prevent a fall. While a patient with hemorrhoids may require special care during insertion of the tip of the rectal tube, this intervention pertains to the patient’s comfort, not to his or her safety. Documenting the patient’s physical response to the enema is appropriate, but this action pertains to recording and reporting, not safety. Instructing the patient to attempt to retain the fluid for 2 to 5 minutes may help make the enema more effective, but will not make it safer. 2. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. B. Place the patient in a side-lying position with the right knee flexed. C. Flush the tube with the solution. D. Hold the tube in the rectum until all of the fluid has been instilled. Rationale: Lubricating the first 6.5 to 7.5 cm facilitates insertion of the rectal tube. Placing the patient in a side-lying position with the right knee flexed aids in retention of the solution. It does not facilitate insertion of the rectal tube. Flushing the tubing with solution will not facilitate insertion of the rectal tube. Holding the tube in the rectum until all of the fluid has been instilled helps minimize the possibility of expelling the rectal tube. It does not, however, facilitate insertion of the tube. 3. The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow-up? A. “I’ll need help to turn her onto her side.” B. “It may take three or four enemas to achieve a clear return.” C. “I’ll test the water temperature on the inside of my own wrist.” D. “The enema will wear her out, so I’ll wait until after she ambulates.” Rationale: Stating it may take three or four enemas to achieve a clear return requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas. This requires no follow-up, since more than one person may be required to turn a patient onto her side. Testing the water temperature on the wrist is appropriate, so this statement requires no follow-up. Stating that the enema will wear her out reflects appropriate concern for the patient and requires no follow-up. 4. The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? A. “I’ll warm up the solution before instilling it.” B. “I’ll place the patient in the left side-lying position with the right knee bent.” C. “I’ll put a waterproof pad under the patient before I start.” D. “I’ll instill the solution and then check in on my other patients until I get the call signal.” Rationale: After instilling the solution, NAP should remain with the patient until he or she is ready to defecate, this statement requires follow-up. Warming the solution is appropriate. The patient is placed in a left side-lying position to allow the solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. A waterproof pad may be placed under the patient if necessary. 5. Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? A. Lubricate the tip of the rectal tube. B. Pad the patient’s bed thoroughly. C. Perform hand hygiene before donning gloves. D. Help the patient onto a bedpan to expel the enema fluid and stool. Rationale: Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff. While lubricating the tip of the rectal tube is appropriate, it pertains to instillation of the enema, not to reducing the risk of infection. Padding the patient’s bed thoroughly is appropriate; it pertains to the patient’s comfort, not to reducing the risk of infection. While helping the patient onto a bedpan is appropriate, it pertains to the procedure itself, not to reducing the risk of infection. 1. How might the nurse safely administer an extended-release capsule to a patient with dysphagia? A. Encourage the patient to drink plenty of water when swallowing the capsule. B. Open the capsule, and place the contents into 90 mL (3 fl. oz.) of juice. C. Place the capsule in a spoonful of the patient’s applesauce. D. Save the capsule to be administered last. Rationale: Placing the capsule in a spoonful of the patient’s applesauce helps lubricate the capsule, thereby facilitating the patient’s ability to swallow it. Although giving the pill whole and encouraging the patient to drink plenty of water when swallowing it is one way to administer the capsule, it is not the safest way. Opening an extended-release capsule is not safe. Changing the sequence in which the medication is administered will not make it safer for the patient to swallow. 2. The nurse is preparing to administer several oral medications when the patient says he would like to take his pills with orange juice. What is the nurse’s best response? A. Determine whether the patient’s prescribed diet includes orange juice. B. Establish whether the medications may be taken with orange juice. C. Ask the dietary aide to order extra orange juice for the unit. D. Administer the pills with orange juice. Rationale: Establishing whether the medications may be taken with orange juice is the nurse’s primary concern. Although determining whether the patient’s prescribed diet includes orange juice is appropriate, establishing if the medication may be given with orange juice is more important. Asking the dietary aide to order extra orange juice is not the nurse’s best response. The nurse must establish whether the medications may be taken with orange juice before agreeing to the patient’s request. 3. Which statement or question best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in administering oral medications? A. “Does the patient need her pain medication?” B. Please make sure the patient has plenty of fresh water to take with her pills.” C. “How much did the pain medication improve her pain?” D. “Stay with the patient until he swallows all the pills.” to NAP the task of providing fresh water to a patient. Patient assessment may not be delegated to NAP. The nurse may not delegate to NAP the responsibility of monitoring a patient during the administration of oral medications. 4. The nurse has provided a patient with a PRN oral analgesic that may be repeated as needed every 6 to 8 hours. What is the most appropriate follow-up action to ensure appropriate pain management? A. Reassess the patient’s pain in 30 to 40 minutes. B. Document the patient’s request for pain medication. C. Administer the pain medication again in 6 hours. D. Include the patient’s pain history in the end-of-shift nursing report. Rationale: Reassessing the patient’s pain in 30 to 40 minutes allows the nurse to gauge whether the analgesic has been effective. Although it is generally appropriate to document the patient’s request for pain medication, doing so is not the most appropriate follow-up intervention of those listed. Administering the pain medication on a schedule, regardless of the patient’s signs and symptoms, is a faulty interpretation of a PRN medication order. Although generally appropriate to include the patient’s pain history in the end-of-shift nursing report, doing so is not the most appropriate follow-up intervention of those listed. 5. A patient with a history of nighttime confusion is to receive several oral medications at bedtime. What is the best way for the nurse to ensure that the patient has swallowed the medication? A. Administer each tablet individually. B. Observe the patient closely as he swallows the tablets. C. Ask the patient to open his mouth after swallowing each tablet. D. Ask the patient to swallow a full glass of water with the tablets. Rationale: Asking the patient to open his mouth after swallowing each tablet allows the nurse to assess for unswallowed medication. Although administering each tablet individually, observing the patient closely as he swallows the tablet, and asking the patient to swallow a full glass of water may be helpful, doing so is not the best way of those listed for the nurse to ensure that the patient has swallowed the medication. 1. When preparing to administer a new medication, what would the nurse do first to ensure the patient’s safety? A. Perform hand hygiene. B. Compare the written order with the medication administration record (MAR). C. Inform the patient about the medication. D. Review appropriate nursing considerations. Rationale: The first step in preparing to administer a new medication would be to perform hand hygiene. Although it is appropriate to compare the written order with the medication administration record (MAR), to inform the patient about the medication, and to review applicable nursing considerations, doing so would not be the nurse’s first step in preparing to administer a new medication. 2. What is the most important step the nurse can take to ensure that the patient is getting the correct medication? A. Assess the patient’s ability to swallow oral medications without difficulty. B. Question the patient about his or her experience with this or similar medications. C. Compare the medication label with the MAR three times. D. Evaluate the patient’s understanding of the safety issues related to the specific drug. Rationale: Comparing the medication label with the MAR three times helps protect the patient from medication administration errors. Although it is appropriate to assess the patient’s swallowing ability, this precaution applies only to oral medications. Although it is appropriate to ask if the patient has had any experience taking the agent or a similar drug, this precaution would not be helpful if the medication were new to the patient. Although it is appropriate to evaluate the patient’s understanding of the safety issues related to the specific drug, doing so is not the most effective way for the nurse to protect the patient. 3. Which statement or question best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in medication administration? A. “Does the patient need her pain medication?” B. “Let me know if she complains of any nausea.” C. “What is the quality of her pain now?” D. “Tell her she doesn’t have an order for the drug she’s asking for.” Rationale: The nurse may delegate to NAP the task of reporting a patient’s symptoms. Patient assessment regarding pain medication and quality of pain may not be delegated to NAP. NAP are not responsible for delivering this kind of information to a patient, since doing so would require educating the patient about his or her medication regimen. Patient education may not be delegated to NAP. 4. As the nurse is administering medication to a patient, the patient states, “I’ve never seen that pill before.” What is the nurse’s most appropriate response? A. Reassure the patient that the pharmacy sent the right medication. B. Tell the patient that it is probably a different brand than what he takes at home and not to worry. C. Tell the patient that you will review the physician’s order to clarify any discrepancies. D. Tell the patient that the doctor probably ordered a new medication. Rationale: If a patient questions a medication, it is important to review the medication orders and revisit the six rights of medication administration. An alert patient will know whether a medication is different from those he or she has received before. 5. What is the nurse’s best response after noticing that the route of administration has been omitted from a medication order? A. Ask which route the patient prefers. B. Immediately notify the prescriber to request that the order be completed. C. Refer to a current drug book to determine the most commonly prescribed route. D. Contact the pharmacy to determine the most appropriate route for this patient. Rationale: The prescriber is required to include all pertinent information on the prescription and should be notified immediately if it is incomplete. Asking which route the patient would prefer is not a safe way of addressing such an omission. Referring to a current drug book for the most commonly prescribed route is not a safe way of addressing such an omission. Contacting the pharmacy is not an appropriate means of addressing an omission in a medication order. 1. A nurse is preparing to help a patient administer a mucolytic agent using a pressurized metered-dose inhaler (pMDI). What will the nurse do first in order to evaluate the medication’s effectiveness? A. Assess the patient’s respiratory status before administration. B. Warn against overuse of the inhaler. C. Discuss the side effects of the particular drug. D. Verify the patient’s identification according to agency policy. Rationale: Assessing the patient’s respiratory status before administration will provide a baseline against which the respiratory status can be compared after administration. Warning against overuse of the inhaler, discussing the side effects of the particular drug, and verifying the patient’s identification are appropriate; doing so will not help the nurse evaluate the drug’s effectiveness. 2. Which discharge instruction would help to ensure that the patient achieves maximum therapeutic delivery of the medication when using a pressurized metered-dose inhaler (pMDI)? A. Make sure to report any adverse effects after using your inhaler. B. Prime the inhaler if it is new or has not been used for several days. C. Hold your breath for 60 seconds after the medication is delivered. D. Use the inhaler while sitting up in a chair at 90-degree angle. Rationale: Priming the inhaler will help to ensure effective dispersion of the medication. Reporting adverse reactions from medication is important, but doing so will not help to ensure accurate delivery. To ensure maximum therapeutic delivery of the medication, the patient would be instructed to hold his or her breath for only 10 seconds, not 60 seconds. The patient need not sit in a particular position while using the inhaler. 3. Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in the use of a metered-dose inhaler? A. “Be sure to let me know if she starts coughing again.” B. “Show the patient how to clean the spacer chamber after she’s finished with the inhaler.” C. “Offer the patient her inhaler if it looks like she’s short of breath.” D. “Please tell her the inhaler is to be used no more than three times per day.” Rationale: The nurse can delegate to NAP the task of reporting such observations. Patient teaching and patient assessment, nor any other aspect of medication administration using a pMDI may be delegated to NAP. 4. A patient has been prescribed a pressurized metered-dose inhaler (pMDI) containing 200 doses of a bronchodilator. The patient has been instructed to take two puffs of the medication three times daily. At this dosage, how long will the MDI last? A. 100 days B. 50 days C. 66 days D. 33 days Rationale: The patient will take 6 doses daily; 200 doses divided by 6 doses per day equals 33 days. The canister does not contain enough medication to last 100, 50, or 66 days. 5. The nurse is instructing a patient who is to receive both a bronchodilator and a steroid medication delivered by means of a pressurized metered-dose inhaler (pMDI). Which instruction is necessary for the safe administration of both agents? A. “Make sure to use the steroid medication before the bronchodilator.” B. “Make sure to use the bronchodilator before the steroid medication.” C. “Rinse your mouth with warm water before using the pMDI to administer either medication.” D. “Make sure you wait at least 30 seconds between administering the bronchodilator and administering the steroid medication.” Rationale: Using the bronchodilator first opens the airways before the steroid is administered, enhancing the effects of both. It is incorrect to administer the steroid before administering the bronchodilator. Rinsing the mouth is appropriate after administration of medication, not before. The patient should wait 2 to 5 minutes, not 30 seconds, between puffs of two separate medications. 1. Which action would the nurse take to ensure the safety of an older adult patient who has received an enema? A. Assess for the presence of external hemorrhoids. B. Provide assistance to the bathroom for expulsion of fluid and stool. C. Document the patient’s physical response to the enema. D. Instruct the patient to attempt to retain the fluid for 2 to 5 minutes. Rationale: Assisting an older adult to the bathroom helps ensure the patient’s safety because it may prevent a fall. While a patient with hemorrhoids may require special care during insertion of the tip of the rectal tube, this intervention pertains to the patient’s comfort, not to his or her safety. Documenting the patient’s physical response to the enema is appropriate, but this action pertains to recording and reporting, not safety. Instructing the patient to attempt to retain the fluid for 2 to 5 minutes may help make the enema more effective, but will not make it safer. 2. The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube? A. Lubricate the first 6.5 to 7.5 cm (2.5 to 3 inches) of the tip of the tube. B. Place the patient in a side-lying position with the right knee flexed. C. Flush the tube with the solution. D. Hold the tube in the rectum until all of the fluid has been instilled. Rationale: Lubricating the first 6.5 to 7.5 cm facilitates insertion of the rectal tube. Placing the patient in a side-lying position with the right knee flexed aids in retention of the solution. It does not facilitate insertion of the rectal tube. Flushing the tubing with solution will not facilitate insertion of the rectal tube. Holding the tube in the rectum until all of the fluid has been instilled helps minimize the possibility of expelling the rectal tube. It does not, however, facilitate insertion of the tube. 3. The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow-up? A. “I’ll need help to turn her onto her side.” B. “It may take three or four enemas to achieve a clear return.” C. “I’ll test the water temperature on the inside of my own wrist.” D. “The enema will wear her out, so I’ll wait until after she ambulates.” Rationale: Stating it may take three or four enemas to achieve a clear return requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas. This requires no follow-up, since more than one person may be required to turn a patient onto her side. Testing the water temperature on the wrist is appropriate, so this statement requires no follow-up. Stating that the enema will wear her out reflects appropriate concern for the patient and requires no follow-up. 4. The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up? A. “I’ll warm up the solution before instilling it.” B. “I’ll place the patient in the left side-lying position with the right knee bent.” C. “I’ll put a waterproof pad under the patient before I start.” D. “I’ll instill the solution and then check in on my other patients until I get the call signal.” Rationale: After instilling the solution, NAP should remain with the patient until he or she is ready to defecate, this statement requires follow-up. Warming the solution is appropriate. The patient is placed in a left side-lying position to allow the solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. A waterproof pad may be placed under the patient if necessary. 5. Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia? A. Lubricate the tip of the rectal tube. B. Pad the patient’s bed thoroughly. C. Perform hand hygiene before donning gloves. D. Help the patient onto a bedpan to expel the enema fluid and stool. Rationale: Performing hand hygiene before donning gloves and after removing them is appropriate in order to reduce the risk of infection among patients and staff. While lubricating the tip of the rectal tube is appropriate, it pertains to instillation of the enema, not to reducing the risk of infection. Padding the patient’s bed thoroughly is appropriate; it pertains to the patient’s comfort, not to reducing the risk of infection. While helping the patient onto a bedpan is appropriate, it pertains to the procedure itself, not to reducing the risk of infection. 1. A female nurse is preparing to administer a rectal suppository to a male patient. The patient says, “This is so embarrassing. Is this really necessary?” What is the most appropriate response? A. “I can see if the doctor will order an oral medication.” B. “How about if I show you how to insert the suppository yourself?” C. “I will make sure that you are well covered. I promise.” D. “This will make you feel so much better.” Rationale: Allowing the patient to self-administer would prevent additional embarrassment. An oral medication may be inappropriate for the patient, for instance, if he is dealing with nausea and vomiting. Although it is appropriate to drape the patient as modestly as possible, doing so does not effectively address the patient’s concern. Reminding the patient of the possible benefits of the medication ignores his concern. 2. The nurse is preparing to administer a rectal suppository to an elderly patient. Which step best protects the patient’s safety? A. Ask the patient to take deep, slow breaths as the suppository is being inserted. B. Insert the suppository 2 inches into the rectum. C. Place the patient in the left side-lying position with the top leg flexed. D. Instruct the patient to use the call light for assistance to the bathroom. Rationale: Reminding the patient to use the call light and making sure it is within reach will help minimize the patient’s risk of falling while trying to walk to the bathroom unassisted. Although asking the patient to relax and breathe deeply is appropriate, this intervention does not pertain to patient safety. A rectal suppository should be inserted 4 inches into the rectum of an adult patient, but the depth does not ensure patient safety. Although placing the patient in the left sidelying position is appropriate, this intervention does not pertain to patient safety. 3. Which statement made by a nurse best illustrates an understanding of the role of nursing assistive personnel (NAP) in administering a rectal suppository? A. “Find out whether the patient is capable of inserting the suppository.” B. “Please tell the patient to report if any rectal bleeding occurs.” C. “Be sure to let me know if the patient has a bowel movement.” D. “Remember to lubricate the suppository.” Rationale: Reporting this type of information to the nurse may be delegated to NAP. Patient assessment, education or evaluation may not be delegated to NAP. The skill of inserting a suppository may not be delegated to NAP. 4. After administering a rectal suppository for constipation, the nurse will monitor for all of the following responses except which one? A. Low platelet count B. Rectal pain C. Bradycardia D. Evacuation of stool Rationale: The nurse must assess for low platelet count before administration of a suppository, not afterward. The nurse must assess for rectal pain, especially during and after insertion of the suppository. The nurse must monitor the patient’s heart rate, because unintended vagal stimulation can slow the heart rate. The nurse would monitor the patient for the desired response, such as evacuation of stool. 5. The nurse should question a provider’s order to insert a suppository into the rectum of a patient with which condition? A. Watery diarrhea B. Rectal inflammation C. External hemorrhoids D. Internal hemorrhoids Rationale: The presence of diarrhea would interfere with the absorption of the medication. Although care should be taken during the insertion of the suppository, rectal inflammation and the presence of internal hemorrhoids does not necessarily preclude administration of a rectal suppository. Although care should be taken to lubricate the suppository and the gloved finger with which it will be inserted, the presence of external hemorrhoids does not necessarily preclude the administration of a rectal suppository.