Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
,TEST BANK
Question 1
Item Type
MCQ
Clinical Scenario
A nurse is preparing to administer a newly prescribed oral
antihypertensive medication to a hospitalized adult. Before
administering the medication, the nurse reviews the patient's
allergies, blood pressure, pulse, recent laboratory results, and
current medications.
Question
Which step of the nursing process is the nurse primarily
performing?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer
,B. Assessment
Comprehensive Rationale
Assessment is the first phase of the nursing process and
establishes the foundation for safe medication administration.
Before giving any medication, the nurse collects subjective and
objective data that may influence therapy. This includes
allergies, vital signs, laboratory values, current medications,
comorbidities, pregnancy status when applicable, and previous
medication responses.
Medication administration without a thorough assessment
increases the risk of adverse drug reactions, contraindications,
and medication errors.
Although pharmacokinetics and pharmacodynamics describe
how medications move through and affect the body,
assessment determines whether administering the drug is
appropriate for the patient's current physiologic condition.
Patient-specific assessment supports individualized
pharmacotherapy and reduces preventable harm.
Distractor Analysis
A. Planning
, Incorrect because planning occurs after assessment and
involves establishing measurable patient-centered outcomes.
Common misconception: Planning begins immediately after
receiving a medication order.
Safety risk: Important contraindications may be overlooked.
Appropriate nursing action: Complete a comprehensive
assessment before planning interventions.
C. Implementation
Incorrect because implementation involves actually
administering the medication and carrying out interventions.
Misconception: Medication administration begins immediately
after verifying the order.
Safety risk: Administering medication before assessment may
cause patient harm.
D. Evaluation
Incorrect because evaluation occurs after medication
administration to determine therapeutic effectiveness and
identify adverse effects.