. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?
Discard the tablet and obtain another dose of medication.
Use the tablet's packaging to pick it up from the counter.
Wash the tablet off with alcohol and place it in a clean medication cup.
Place the tablet directly into a medication cup.
The Correct Answer is A
A. Discarding the tablet and obtaining another dose is the safest option, as it ensures the medication's integrity and prevents any potential contamination.
B. Using the tablet's packaging to pick it up is not appropriate as it could introduce contaminants from the surface of the counter to the tablet.
C. Washing the tablet with alcohol is not advisable because it could alter the medication's properties or effectiveness.
D. Placing the tablet directly into a medication cup without addressing its contamination would also be inappropriate and could jeopardize client safety.
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Correct Answer is D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.
Correct Answer is C
Explanation
A. Obtaining the client's consent is the responsibility of the provider, not the nurse. The nurse should ensure the client is informed but cannot independently obtain consent.
B. It is not within the nurse's scope of practice to explain the procedure in detail; this is the responsibility of the healthcare provider. The nurse can clarify information if the client has questions but should not assume the role of the educator regarding the procedure.
C. Witnessing the client's signature is an appropriate action for the nurse once the client has received information from the provider and understands the procedure, as it confirms that the client voluntarily consents.
D. Explaining the risks and benefits of the procedure is also the responsibility of the healthcare provider, as they are the ones performing the procedure and are qualified to discuss it in detail.