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 C
Explanation
Choice A rationale
Replacing the external urinary catheter once each day is unnecessary. The catheter should be changed based on clinical judgment and manufacturer's guidelines to maintain hygiene.
Choice B rationale
Inserting the catheter into the client's urethra is incorrect for an external urinary catheter. External catheters are designed to be placed outside the body.
Choice C rationale
Applying a barrier cream to the client's perineal skin is correct. Barrier creams protect the skin from moisture and prevent skin breakdown and irritation caused by urine.
Choice D rationale
Connecting the catheter to continuous wall suction is not appropriate. External urinary catheters should be connected to a drainage bag for proper urine collection. .
Correct Answer is C
Explanation
Choice C rationale
The large intestine absorbs water and electrolytes from the remaining indigestible food matter, forming and eliminating solid waste (stool). This absorption process is vital for
maintaining the body's fluid and electrolyte balance.
Choice A rationale
The large intestine does not produce vitamin D; this occurs in the skin when exposed to sunlight. The large intestine’s primary functions are absorption and waste formation.
Choice B rationale
Preventing the reflux of food into the esophagus is the function of the lower esophageal sphincter, not the large intestine. The large intestine deals with waste processing rather than regulating esophageal function.
Choice D rationale
The secretion of digestive enzymes is a function of the pancreas, stomach, and small intestine. The large intestine does not secrete enzymes but focuses on absorbing water and electrolytes.