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 D
Explanation
Choice A rationale
It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.
Choice B rationale
Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.
Choice C rationale
Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.
Choice D rationale
Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.
Correct Answer is D
Explanation
Choice A rationale
Aging usually leads to a decrease in muscle tone of the bowel rather than an increase, which can result in slower bowel movements and constipation.
Choice B rationale
Gastric acid production tends to decrease with age, not increase. This can affect the digestion and absorption of nutrients, and also increase the risk of stomach infections.
Choice C rationale
The pH of the stomach tends to become less acidic (increase) as one ages, not decrease. This is often due to the reduced production of gastric acid.
Choice D rationale
Decreased intestinal peristalsis is a common physiological change in older adults. This slowing down of the intestinal movements can lead to constipation and other digestive issues.