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 C
Explanation
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.
Correct Answer is A
Explanation
A. Applying petroleum jelly to the client's lips after oral care helps to prevent dryness and cracking, especially important for immobile clients who may have decreased hydration.
B. A stiff toothbrush can cause damage to the gums and teeth; a soft-bristled toothbrush is preferable for gentle cleaning.
C. Using the thumb and index finger to keep the client's mouth open can cause discomfort; a tongue blade or a mouth prop may be a better option if needed.
D. While turning the client on their side can help if there is a risk of aspiration, it is not always necessary for every oral care session and depends on the client's specific condition.