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
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.
Correct Answer is D
Explanation
Choice A rationale
Instilling ophthalmic medication directly on the cornea can cause irritation and discomfort. Medications should be administered in the conjunctival sac.
Choice B rationale
Asking the client to tightly squeeze their eyes shut after instillation can expel the medication, reducing its effectiveness. Gentle closing of the eyes is recommended.
Choice C rationale
Cleaning the eye from the outer canthus to the inner canthus is not the proper method. The correct method is to clean from the inner canthus to the outer canthus to avoid contaminating the inner eye.
Choice D rationale
Applying pressure to the nasolacrimal duct after instillation helps prevent the medication from draining into the nasolacrimal system, ensuring better absorption in the eye.