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A nurse is administering oral medications to patients. Which action will the nurse take?

A.

Measure liquid medication by bringing liquid medication cup to eye level.

B.

Crush enteric-coated medication and place it in a medication cup with water.

C.

Place all of the client's medications in the same cup, except medications with assessments.

D.

Remove the medication from the wrapper and place it in a cup labeled with the client's information.

Answer and Explanation

The Correct Answer is A

A) Measure liquid medication by bringing liquid medication cup to eye level: This is the correct action. Measuring liquid medications at eye level ensures accuracy and helps the nurse confirm the correct dosage, minimizing the risk of administration errors.

 

B) Crush enteric-coated medication and place it in a medication cup with water: This option is incorrect. Enteric-coated medications are designed to dissolve in the intestine, not in the stomach, and crushing them can alter their effectiveness and increase the risk of side effects. These medications should be administered whole.

 

C) Place all of the client's medications in the same cup, except medications with assessments: This option is not advisable without knowing how the medications interact. Certain medications may have specific requirements for administration and should not be mixed together, as this could lead to confusion or adverse reactions.

 

D) Remove the medication from the wrapper and place it in a cup labeled with the client's information: While labeling is crucial for safety, medications should ideally be kept in their original packaging until administration to prevent confusion and ensure that the nurse has all necessary information about the medication at hand. Medications should only be removed when preparing for immediate administration.


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Correct Answer is A

Explanation

A) Should not be swallowed because it alters the absorption potential: This is the correct explanation. Sublingual medications, such as nitroglycerin, are designed to be absorbed quickly through the mucous membranes under the tongue. Swallowing the medication can significantly reduce its effectiveness and delay absorption, which is crucial for medications used in acute situations like angina.

B) Can be held against the roof of the mouth with the tongue to reduce taste: This option is not correct. Holding the medication against the roof of the mouth does not facilitate the intended sublingual absorption and may not significantly mitigate the taste issue. The medication needs to dissolve under the tongue for effective absorption.

C) Can be inserted rectally without loss of absorption potential: This option is incorrect. Sublingual medications are formulated for absorption through the sublingual mucosa and would not provide the same effects if administered rectally. Different routes of administration have different absorption profiles.

D) Can be taken between the cheek and tongue to diminish taste: While this may help with taste, it does not achieve the desired sublingual absorption. For optimal effect, the medication should be held under the tongue, where it can dissolve and be absorbed directly into the bloodstream.

Correct Answer is B

Explanation

A) Ask the client if he would prefer to give the medication to himself: While involving the client in their care is important, this option does not assess the client’s ability to safely take the medication. The nurse should first ensure that the client can swallow the medication safely.

B) Assess the swallowing reflex by offering a sip of water: This is the correct action. Assessing the swallowing reflex is essential, especially in older adults, to determine if they can safely swallow liquid medications without risk of aspiration.

C) Mix thoroughly in applesauce or pudding: This option is not appropriate unless specifically ordered or indicated. Mixing medications in food may not be suitable for all clients, and it can affect the medication's absorption or effectiveness. Additionally, it does not assess the client's swallowing ability.

D) Assess the ability to understand information relative to the medication: While this is important, it is secondary to ensuring that the client can physically take the medication safely. Assessing understanding can occur after confirming the client’s ability to swallow the medication.

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