A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?
In the area where the nurse obtained the medication.
At the time of documentation.
At the client's bedside before administration.
At the nurses' station while reviewing the provider's prescription.
The Correct Answer is C
A. Performing the final medication check in the area where the medication was obtained does not ensure the correct patient is receiving the medication.
B. Documenting after administration does not allow for a final check of the medication against the patient’s identity and allergies.
C. Performing the final check at the client's bedside before administration allows the nurse to confirm the patient's identity, the medication's appropriateness, and the dosage immediately before giving it.
D. Reviewing the prescription at the nurses' station may not account for patient-specific factors that need to be confirmed at the bedside.
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Correct Answer is A
Explanation
A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.
B. Documenting that the medication was administered should occur after the medication has been given, not before.
C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.
D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.