A nurse is administering a powdered medication to a client.
Which of the following actions should the nurse take first?
Document that the medication was administered.
Mix the medication at the client's bedside.
Check the client for allergies.
Determine the client's response to the medication.
The Correct Answer is C
Choice A rationale
Documenting the medication administration is important but should be done after administering the medication. Documentation ensures proper tracking and accountability but does
not address immediate patient safety concerns like checking for allergies.
Choice B rationale
Mixing the medication at the client's bedside may ensure that the medication is prepared correctly and the client receives it promptly, but it doesn't address the critical step of
ensuring the client's safety by checking for allergies first.
Choice C rationale
Checking the client for allergies is crucial before administering any medication, including powdered forms. Allergic reactions can be severe or life-threatening, so it’s essential to
ensure that the client isn’t allergic to the medication. This step ensures the safety and well-being of the client and prevents potential adverse reactions.
Choice D rationale
Determining the client's response to the medication is important for assessing the medication's effectiveness and identifying any adverse reactions, but it occurs after administration.
Checking for allergies precedes all these steps to prevent any initial harm.
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Correct Answer is A
Explanation
Choice A rationale
Neobladder urinary diversion involves creating an internal reservoir or pouch from a segment of the intestine to store urine. This new bladder is then connected to the urethra,
enabling the client to void through the urethra. This method closely mimics natural urination, allowing the client to have some control over urination.
Choice B rationale
This is incorrect because a neobladder is designed to allow the client to control urination. While there might be a learning curve for the client to adapt to the new bladder, the ultimate
goal is to achieve continence.
Choice C rationale
This describes an ileal conduit, another type of urinary diversion, where a stoma is created on the abdomen for urine to pass into an external bag. The neobladder does not involve a
stoma for urination.
Choice D rationale
This is incorrect as it pertains to an ileal conduit or urostomy. Clients with a neobladder do not require an external collection bag since urine is stored internally in the constructed
bladder and can be passed through the urethra. .
Correct Answer is D
Explanation
Choice A rationale
Collecting two stool specimens from the same area of the stool is incorrect because specimens should be taken from different areas to ensure a representative sample of the stool for testing.
Choice B rationale
Using toilet paper to transfer the stool specimen is not recommended as it can contaminate the sample and interfere with test results.
Choice C rationale
Applying four drops of developing solution to each stool specimen is incorrect. The usual procedure involves applying a specific number of drops as indicated by the test instructions, which may vary.
Choice D rationale
Waiting 30 seconds after applying the developing solution is correct. This waiting period allows the test to react and provide accurate results for the presence of occult blood.