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 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 ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.