Nursing Jurisprudence and Ethics for Texas Nurses Practice Exam

What documentation is necessary when a nurse administers a medication?

1. Only the medication name and dosage

2. The medication name, dosage, route, time, and patient response

3. Medications do not require any documentation

4. Just the medication and the nurse's signature

The correct answer is: The medication name, dosage, route, time, and patient response

The necessity for comprehensive documentation when a nurse administers medication stems from a commitment to patient safety, legal compliance, and professional accountability. It is essential to include the medication name, dosage, route of administration, time it was given, and the patient's response to the medication in the documentation. Each of these elements plays a critical role in ensuring proper medication management and facilitating effective communication among healthcare team members. Including the medication name and dosage confirms what was actually administered, while the route indicates how the medication was given, which can impact its effectiveness. Documenting the time of administration is crucial for maintaining accurate treatment schedules and monitoring medication effects, as well as for compliance with legal and regulatory standards. Lastly, noting the patient's response allows for the evaluation of the drug's efficacy and any potential side effects or reactions, which is vital for ongoing patient care and assessment. Inadequate documentation, such as including only limited information or failing to document at all, can lead to misunderstandings, errors in care, and potential legal ramifications. Therefore, a thorough and precise documentation process is not merely best practice; it's a critical component of nursing responsibilities.