A nurse is administering oral medications to patients. Which action will the nurse take?
Measure liquid medication by bringing liquid medication cup to eye level.
Crush enteric-coated medication and place it in a medication cup with water.
Place all of the client's medications in the same cup, except medications with assessments.
Remove the medication from the wrapper and place it in a cup labeled with the client's information.
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 C
Explanation
A) A client who has a question about her daily medications: While it's important to address questions regarding medications, this client does not present an immediate clinical concern that requires urgent attention.
B) A client who needs discharge teaching about an antibiotic: Although discharge teaching is important, it is not an immediate priority compared to the potential instability of a client with chest pain.
C) A client who just received nitroglycerin for chest pain: This is the correct choice. A client who has received nitroglycerin needs to be closely monitored for its effects, including blood pressure and relief of chest pain. This situation is potentially critical, making it the highest priority for assessment.
D) A client who would like some acetaminophen (Tylenol) for a mild headache: While this request should be addressed, it is not as urgent as the need to assess the client who has recently received nitroglycerin. Managing a mild headache is less critical compared to monitoring a client with chest pain.
Correct Answer is C
Explanation
A) Apply it behind the ear: This option is not correct. Nitroglycerin patches are typically applied to hairless areas of the skin to ensure proper adhesion and absorption. The preferred locations are usually the chest, upper arm, or thigh.
B) Place it over a hairy skin area: This action is inappropriate as hair can interfere with the adhesion of the patch and may affect absorption. It is essential to apply the patch to a clean, dry, and hairless area for optimal effectiveness.
C) Rotate sites to avoid skin irritation: This is the correct action. Rotating the application site helps prevent skin irritation and allows for better absorption of the medication. It also reduces the risk of sensitization or reaction at any one site.
D) Put the initials on the patch when applied: While documenting the application is important, simply putting initials on the patch is not sufficient for ensuring proper administration. It is more crucial to ensure that the patch is applied correctly, and monitoring for skin integrity and effectiveness should be part of the nursing care plan.