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 B
Explanation
Choice A rationale
An ileal conduit does not provide the client with control over elimination. It is a type of urinary diversion, and the client wears an external pouch to collect urine.
Choice B rationale
In an ileal conduit, the client's ureters are attached to a section of the small intestine, which is then brought to the surface of the abdomen to form a stoma. Urine flows through this conduit into an external pouch.
Choice C rationale
An ileal conduit is not a tube that directly connects the kidney to an external pouch. It involves using a section of the small intestine to create a passageway for urine to exit the body.
Choice D rationale
Stool is not passed through an ileal conduit. The ileal conduit is specifically for urinary diversion, while stool passes through the regular gastrointestinal tract.
Correct Answer is D
Explanation
Choice A rationale
A sigmoid colostomy usually produces stool that is more formed compared to an ileostomy. This is because the colostomy is created from the sigmoid colon, where water absorption occurs.
Choice B rationale
The stoma should not be painful after the procedure. Pain may indicate complications, and the stoma itself lacks nerve endings.
Choice C rationale
The stoma should be a bright red or pink color, indicating good blood supply. A purple color could suggest ischemia or poor blood flow.
Choice D rationale
A sigmoid colostomy is typically located in the left lower abdomen because the sigmoid colon is situated in this area of the body.