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","B","C"]
Explanation
Choice A rationale
Anticholinergics/antispasmodics can cause constipation by reducing the muscle contractions of the gastrointestinal tract, leading to slower movement of contents and resulting in constipation.
Choice B rationale
Opioid narcotics cause constipation by binding to opioid receptors in the gastrointestinal tract, which decreases intestinal motility and inhibits the secretion of fluids, leading to hard and dry stools.
Choice C rationale
Iron supplements can cause constipation as a common side effect due to their effect on the gastrointestinal tract. They can make stools harder and more difficult to pass.
Choice D rationale
Magnesium-containing antacids typically do not cause constipation. In fact, they are more likely to have a laxative effect due to the presence of magnesium, which can increase water in the intestines and soften stools.
Correct Answer is C
Explanation
Choice A rationale
The end of the stoma is typically not painful after the procedure. Pain at the stoma site could indicate complications such as infection or ischemia.
Choice B rationale
A healthy stoma should be pink or red in color. A purple color could indicate compromised blood flow or other complications that require medical attention.
Choice C rationale
The stoma is typically placed in the right lower abdomen to allow for easier management and care, as it is usually associated with the terminal ileum.
Choice D rationale
After an ileostomy, the stool is usually liquid to semi-formed, not solid, because the colon, which absorbs water to solidify stool, is bypassed.