Certified Medical-Surgical Registered Nurse Practice Exam

Which action by the nurse is necessary after administering medication to a patient?

1. Documenting the administration immediately

2. Waiting until the end of the shift to document

3. Informing the physician about the medication

4. Verifying if the patient understands the medication

The correct answer is: Documenting the administration immediately

Documenting the administration immediately after giving medication is a critical step in ensuring patient safety and maintaining accurate medical records. This action helps to create a clear timeline of care, which is essential for continuity and coordination amongst all healthcare team members. Immediate documentation decreases the risk of errors, such as administering the same medication again if documentation is delayed or forgotten. While verifying a patient's understanding of the medication is important for informed consent and patient autonomy, it does not replace the necessity of documenting the administration promptly. Informing the physician after giving medication may be required in some contexts, but it is not a standard protocol for every medication given. Additionally, waiting until the end of the shift to document can lead to inaccuracies and potential legal issues, making it imperative to document as soon as the medication has been administered.