Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
TEST BANK
,Question 1
Item Type
Multiple Choice (MCQ)
Clinical Scenario
A nurse is preparing to administer the first dose of an oral
antihypertensive medication to a 67-year-old patient admitted
with newly diagnosed hypertension. The patient states, "I've
never taken medicine for blood pressure before."
Question Stem
Which nursing action should be performed first before
administering the medication?
Answer Options
A. Explain the possible adverse effects of the medication.
B. Measure and document the patient's blood pressure and
heart rate.
C. Administer the medication with food.
D. Teach the patient to rise slowly from a sitting position.
Correct Answer
B. Measure and document the patient's blood pressure
and heart rate.
,Comprehensive Rationale
The nursing process begins with assessment. Before
administering medications that influence cardiovascular
function, the nurse should obtain baseline vital signs to
determine whether the medication is appropriate and safe to
administer. Baseline assessment provides essential information
for evaluating therapeutic response and identifying
contraindications, such as hypotension or bradycardia.
Assessment findings guide clinical decision-making, help
prevent medication-related harm, and establish comparison
data for evaluating treatment effectiveness.
Medication teaching and implementation occur only after
confirming the medication can be safely administered.
Distractor Analysis
Option A
Why Incorrect
Patient education is important but should follow completion of
the assessment.
Common Misconception
Believing teaching always precedes assessment.
, Medication Safety Risk
Potential administration despite abnormal vital signs.
Appropriate Nursing Action
Assess first, then educate.
Option C
Why Incorrect
Whether medication should be taken with food depends on the
specific medication prescribed.
Common Misconception
Assuming all medications should be given with meals.
Medication Safety Risk
Reduced drug absorption or altered pharmacokinetics.
Appropriate Nursing Action
Verify administration instructions after assessment.
Option D
Why Incorrect
Teaching regarding orthostatic hypotension is appropriate after
determining medication safety.