The nursing process and drug therapy – Flashcards
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The nurse answers a patient's call light and finds the patient sitting up in the bed and requesting pain medication. What will the nurse do first? A. Check the orders and give the patient the requested pain medication B. Provide comfort measures to the patient C. Assess the patient's pain and pain level D. Evaluate the effectiveness of previous medications
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C. Assess the patient's pain and pain level
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A nurse makes and error when administering medications to a patient. Which action by the nurse requires the supervising nurse to intervene? The nurse A. completes an incident report B. informs the prescriber of the error C. documents adverse effects to the medication error D. records completion of an incident report in the medical chart
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D. records completion of an incident report in the medical chart
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- ONGOING part of the nursing process -Determining the STATUS OF THE GOALS AND OUTCOME of care - Monitoring the PATIENT'S RESPONSE to drug therapy (Expected and unexpected responses ) -Clear concise DOCUMENTATION
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EVALUATION
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The day shift charge nurse is making rounds . A patient tells the nurse that the night shift nurse never gave him his medication, which was due at 2100. What will the nurse do first to determine whether the medication was given ? A. Call the night nurse at home B. Check the Medication Administration Record C. Call the pharmacy D. Review the nurse's notes
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B. Check the Medication Administration Record The
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The patient's medication administration record lists tow antiepileptic medications that are due at 0900, but the patient is NPO for a study. The nurse's coworker suggests giving the medications via IV because the patient is NPO. What will the nurse do? A. Give the medications PO with a small sip of water B. Give the medications via the IV route because the patient is NPO C. Hold the medications until after the test is completed D. Call the health care provider to clarify the instructions
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D. Call the health care provider to clarify the instructions
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DATA collection, review, and analysis MEDICATION profile - any and all drug use - Prescription - over the counter medications - vitamins, herbs, and supplements - compliance and adherence
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ASSESSMENT
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ND are used to communicate and share about the patient and the patient experience Common Nursing diagnosis related to drug therapy include: - deficient knowledge - risk for injury - non compliance
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NURSING DIAGNOSIS
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Nursing Diagnosis 3 Step process - Human response to illness, injury, or significant change - Factors related to the response ('related to") - Listing of cues, clues, evidence, or other data that support the nurse's claim for the diagnosis ("as evidence by")
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Three step process
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- Identification of goals and outcome criteria - Goals objective, measurable, and realistic with an established time period for achievement of the outcomes that are specifically stated in the outcome criteria -OUTCOME CRITERIA concrete description of patient goals
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Planning
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The Nursing Process -A research-based organizational framework for professional nursing practice -Ensures the delivery of thorough, individualized, and quality nursing care to patients =Requires critical thinking = Ongoing and constantly evolving process
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The Nursing Process -A research-based organizational framework for professional nursing practice
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Five Steps of The Nursing Process - Assessment - Nursing DIAGNOSIS (problem statement) - Planning goals outcome criteria -Implementation - Evaluation
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Five Steps of The Nursing Process - Assessment - Nursing DIAGNOSIS (problem statement) - Planning goals outcome criteria -Implementation - Evaluation
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Which phase of the nursing process requires the nurse to establish a comprehensive baseline of data concerning a particular patient? A. Assessment B. Planning C. Implementation D. Evaluation
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Assessment
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The nurse monitors the fulfillment of goals, and may revise them, during which phase of nursing process? A. Assessment B. Planning C. Implemenation D. Evaluation
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D. Evaluation
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The nurse prepares and administers prescribed medications during which phase of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation
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C. Implementation
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When developing a plan of care, which nursing action ensures the goal statement is patient centered? A. Considering family input B. Involving the patient C. Developing the goal first and then sharing it with the patient D. Including the physician
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B. Involving the patient
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The nurse includes which information as part of a complete medication profile? (Select all that Apply) A Use of "stress" drugs B. Current laboratory work C. History of surgeries D. Use of alcohol E. Use of herbal products F. Family history
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A Use of "stress" drugs D. Use of alcohol E. Use of herbal products
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During which phase of the nursing process does the nurse prioritize the nursing diagnosis? A. Assessment B. Planning C. Implementation D. Evaluation
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B. Planning
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The nurse is preparing to administer morning doses of medications to a patient and has just checked the patient's name the identification band. The patients has stated his name. Which is the nurse's next appropriate action? A. Administer the medication B. Ask the patient's wife to verify the patients identity C. Ask the patient to verify his date of birth D. Check the chart for the patient's date of birth
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C. Ask the patient to verify his date of birth
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The nurse is administering a medication and the order reads: "Give 250 mcg PO now" The tablets in the medication dispensing cabinet are in milligram strength. What is the right dose of the drug in milligrams?
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0.25mg
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The nurse is administering a medication and the order reads: Give 0.125 mg PO now " the tablets in the medication dispensing cabinet are microgram strength. What is right dose of the drug in micrograms?
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125 mcg
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Place the steps of the nursing process in order, with 1 being the first step and 5 being the last steps A. Implementation B. Planning C. Evaluation D. Assessment E. Formulation of nursing diagnosis
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D. Assessment E. Formulation of nursing diagnosis B. Planning A. Implementation C. Evaluation
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The nurse is attempting to administering the morning dose of the medication. The patient refuses the medication stating. "It makes me sick to my stomach." What is the nurse's responsibility? A. Document the patient's refusal in the record B. Discard the medication according to hospital policy C. Disguise the medication in food D. Offer the medication again in 30 minutes
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A. Document the patient's refusal in the record
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Which medication is appropriately administered at the correct time? A. Amoxicillin ordered at 0800 and given at 0700 B. Cardizem ordered at 0900 and given at 0930 C. Furosemide ordered at 0730 and given at 0825 D. Synthroid ordered at 1000 and given at 0915
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B. Cardizem ordered at 0900 and given at 0930
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Subjective or Objective Ms B, tells the nurse, that she smokes a pack of cigarettes a day.
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Subjective
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Subjective or Objective She is 5 feet 5 inches tall and weighs 135 lbs.
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Objective
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The nurse finds that Ms. B's pulse rate is 68 beats/min, and her blood pressure is 128/72mm Hg
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Objective
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Her stool was tested for occult blood by a laboratory technician; the results were negative
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Objective
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Ms B. Says that she does not experience nausea, but she reports pain and heartburn, especially after eating popcorn something she and her husband have always done while watching TV before bedtime.
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Subjective
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She experiences occasional increases in stomach pain, a "feeling of heat" in her abdomen and chest at night when she lies down, and increased incidents of heartburn
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Subjective
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Data are collected during the _______ phase of the nursing process
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Assessment
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Data can be classified as _______ or _______
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Objective , Subjective
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The formulate the nursing diagnosis, the nurse must first ________ the information collected.
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Analyze
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The ___________ phase consists of carrying out the nursing care plan.
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Implementation
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The _________ phase is ongoing and includes monitoring the patient's response to medication and determining the status of goals.
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Evaluation
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An 86 year old patient is being discharged to home on on digitalis therapy and has very little information regarding the medications. Which statement best reflects a realistic outcome of patient teaching activities? A. The patient i and patient's daughter will state the proper way to take the drug B. The nurse will provide teaching about the drug's adverse effects C. The patient will state all the symptoms of digitalis toxicity D. The patient will call the prescriber if adverse effects occur
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A. The patient i and patient's daughter will state the proper way to take the drug
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A patient has a new prescription for a blood pressure medication that may cause him to feel dizzy during the first few days of therapy. Which is the best nursing diagnosis for this situation A. Activity intolerance B. Risk for injury C. Disturbed body image D. Self-care deficit
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B. Risk for injury
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A patient's chart includes an order that reads as follows: "Atenolol 25mg once daily at 0900" which action by the nurse is correct? A. The nurse gives the drug via the transdermal route B. The nurse gives the drug orally C. The nurse gives the drug intravenously D. The nurse contacts the prescriber to clarify the dosage route
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D. The nurse contacts the prescriber to clarify the dosage route
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The nurse is compiling a drug history for a patient. Which question from the nurse will obtain the most information from the patient? A. "Do you depend on sleeping pills to get to sleep?" B. "Do you have a family history of heart disease?" C. "When you have pain, what do you do to relieve it?" D. "What childhood diseases did you have?"
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C. "When you have pain, what do you do to relieve it?"
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A 77 year old man who has been diagnosed with and upper respiratory tract infection tells the nurse that he is allergic to penicillin. Which is the most appropriate response by the nurse? A " many people are allergic to penicillin" B. " This allergy is not of major concern because the drug is given so often" C. "what type of reaction did you have when you took penicillin?" D. Drug allergies dont' usually occur in older individuals due to built up resistance to allergic reactions."
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C. "what type of reaction did you have when you took penicillin?"
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The nurse is preparing a care plan for a patient who has been newly diagnosed with type 2 diabetes mellitus. Which of these reflect the correct order of of the steps of the nursing process? A. Assessment, Planning, Nursing Diagnosis, Planning, implementation B. Evaluation, Assessment, Nursing Diagnosis, Planning implementation C. Nursing Diagnosis, Assessment, Planning implementation, evaluation
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D. Assessment, Nursing Diagnosis, Planning implementation, Evaluation
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The nurse is reviewing new medication orders that have been written for a newly admitted patient. The nurse will need to clarify which orders? (Select all that apply) A. Metformin ( Glucophage) 1000mg PO twice a day B. Sitagliptin ( Januvia) 50mg daily C. Simvastain (Zocor) 20mg PO every evening D. Irbesartan (Avapro) 300 mg PO once a day E. Docusate (Colace) as needed for constipation
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B. Sitagliptin ( Januvia) 50mg daily E. Docusate (Colace) as needed for constipation
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The nurse is reviewing data collected from a medication history. Which of these data are considered objective data? (select all that apply) A. White blood cell count 22,000mm B. Blood pressure 150/94 mm Hg C. Patient rates pain as an 8 on a 10 point scale D. Patient's wife reports that the patient has been very sleepy during the day E. Patient's weight in 68 kg
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A. White blood cell count 22,000mm B. Blood pressure 150/94 mm Hg E. Patient's weight in 68 kg
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In which step of the nursing process does the nurse determine the outcome of medication administration? A. Planning B. Evaluation C. Assessment D. Implementation
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B. Evaluation It is systematic, ongoing, and a dynamic phase of the nursing process as related to drug therapy. It includes monitoring the fulfillment of outcomes and monitoring the patient's therapeutic response to the drug and its adverse effects and toxic effects. The planning phase prioritizes the nursing diagnoses and specifies outcomes. Assessment allows you to organize the information and place it into meaningful categories. Implementation consists of initiating and completion of specific nursing actions as defined by nursing diagnoses.
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The nurse plans care for a male patient who is 80 years old. The nursing diagnosis is noncompliance with the medication regimen related to living alone, as evidenced by uncontrolled blood pressure. What should the nurse do next? A. Enlist the help of a home care nurse for pharmacotherapy. B. Examine the results of nursing help with the medications. C. Collaborate with the provider on a new medication regimen. D. Assess the impact of home self-management of medications.
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A. Enlist the help of a home care nurse for pharmacotherapy. After establishing the nursing diagnosis, the nurse plans care by determining the nursing goals and outcome criteria. As a means of working toward blood pressure control, the nurse chooses to set up nursing assistance for the patient in the home. The home care nurse can help the patient adhere to the therapeutic regimen by making a medication schedule and dispensing medication into a pill box, among other strategies. The nurse assesses the patient before establishing the nursing diagnosis and evaluates care after implementing the plan. Collaboration on a new medication regimen is not indicated. Examining the results of nursing help with the medications is part of the evaluation process to determine if the plan was effective. Collaboration on a new medication regimen is not indicated. The nurse assesses the patient before establishing the nursing diagnosis and evaluates care after implementing the plan.
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Which statement is an example of objective data? (Select all that apply.) A. The patient states that she has a headache. B. The patient has clear urine. C. The patient says that she feels like someone is touching her arm. D. The patient has had a fever for 5 days. E. The patient says that she has felt tired for almost a week.
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B. The patient has clear urine. Correct D. The patient has had a fever for 5 days. Objective data may be defined as any information gathered through the senses or that is seen, heard, felt, or smelled. Objective data may also be obtained from a nursing physical assessment; nursing history; past and present medical history; results of laboratory tests, diagnostic studies, or procedures; measurement of vital signs, weight, and height; and medication profile. Subjective data include information shared through spoken word by any reliable source, such as the patient, spouse, family member, significant other, or caregiver
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What things should the nurse check when reviewing a prescription with a patient? (Select all that apply.) A. The patient's home address B. The route of administration C. The age of the patient D. The signature of the prescriber E. The patient's emergency contact
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B. The route of administration D. The signature of the prescriber After assessment of the patient and the drug has been completed, the specific prescription or medication order from any prescriber must be checked for the following seven elements: (1) patient's name, (2) date the drug order was written, (3) name of drug(s), (4) drug dosage amount, (5) drug dosage frequency, (6) route of administration, and (7) prescriber's signature
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What information should the nurse chart when documenting medication administration? (Select all that apply.) A. The time of administration B. Information about an "incident report" in the patient's chart C. The patient's age D. The route of administration E. The dosage of medication administered
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A. The time of administration D. The route of administration E. The dosage of medication administered Documentation of administration is one of the nine rights of patient medication administration and should include patient response, teaching related to the medication, if the medication is not given, refusal of medication, and reason for refusal. Medication errors should be noted in an incident report but should not be documented as an incident report in the patient's chart. Information about "incident report" is never placed in the patient's chart but is sent to risk management. The patient's age is already a part of the patient's record and is not needed in the documentation of administration.
