Process
10th Edition
• Author(s)Linda Lane Lilley;
Shelly Rainforth Collins; Julie
S. Snyder
TEST BANK
,Question 1 (MCQ)
Clinical Scenario
A nurse is preparing to administer a newly prescribed
antihypertensive medication to a hospitalized patient. Before
administration, the nurse reviews the patient's blood pressure,
allergies, current medications, and recent laboratory results.
Question Stem
Which nursing process step is the nurse primarily performing?
Answer Options
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer
B. Assessment
Comprehensive Rationale
Assessment is the first step of the nursing process and involves
collecting, validating, organizing, and documenting patient
,information relevant to medication therapy. Before
administering a medication, the nurse gathers clinical data such
as vital signs, allergies, laboratory findings, medication history,
and patient symptoms to determine whether medication
administration is appropriate and safe.
Assessment supports medication safety by identifying factors
that may alter pharmacokinetics (absorption, distribution,
metabolism, excretion) and pharmacodynamics (drug effects at
receptor sites).
For antihypertensive medications, assessment may include:
• Blood pressure and heart rate
• Electrolyte values
• Renal function
• Medication interactions
• Patient adherence history
• Allergies and adverse drug reactions
Conducting a thorough assessment helps prevent medication
errors and supports individualized pharmacotherapy.
Distractor Analysis
A. Planning
, Why Incorrect:
Planning occurs after assessment and involves establishing
goals and expected outcomes.
Common Misconception:
Some learners confuse collecting data with establishing goals.
Medication Safety Risk:
Goals may be inappropriate if based on incomplete assessment
data.
Appropriate Nursing Action:
Assess first, then develop measurable outcomes.
C. Implementation
Why Incorrect:
Implementation involves carrying out nursing interventions,
including medication administration.
Common Misconception:
Students often think preparation automatically means
implementation.
Medication Safety Risk:
Administering medication before adequate assessment
increases risk of harm.