Before the nurse administers a liquid medication to an 83-year-old male client, the nurse should:
ask the client if he would prefer to give the medication to himself.
assess the swallowing reflex by offering a sip of water.
mix thoroughly in applesauce or pudding.
assess the ability to understand information relative to the medication.
The Correct Answer is B
A) Ask the client if he would prefer to give the medication to himself: While involving the client in their care is important, this option does not assess the client’s ability to safely take the medication. The nurse should first ensure that the client can swallow the medication safely.
B) Assess the swallowing reflex by offering a sip of water: This is the correct action. Assessing the swallowing reflex is essential, especially in older adults, to determine if they can safely swallow liquid medications without risk of aspiration.
C) Mix thoroughly in applesauce or pudding: This option is not appropriate unless specifically ordered or indicated. Mixing medications in food may not be suitable for all clients, and it can affect the medication's absorption or effectiveness. Additionally, it does not assess the client's swallowing ability.
D) Assess the ability to understand information relative to the medication: While this is important, it is secondary to ensuring that the client can physically take the medication safely. Assessing understanding can occur after confirming the client’s ability to swallow the medication.
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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.
Correct Answer is D
Explanation
A) While administering the eye drops, a drop lands on the client's outer lid, so the client administers another drop: This action requires further teaching. If a drop lands outside the eye, the client should not administer another drop without first cleaning the area. It’s important to avoid excessive dosing and to ensure the medication is delivered properly.
B) The client cleans the eye from the inner to the outer canthus: This is the correct technique. Cleaning the eye from the inner canthus to the outer canthus helps prevent the spread of debris and ensures a clean area for administering drops.
C) The client looks upward toward the ceiling and administers the eye drops in the conjunctival sac: This action is appropriate. Looking upward helps expose the conjunctival sac, making it easier to administer the drops effectively.
D) The client touches the conjunctival sac with the eyedropper to make sure she is in the correct location: This action requires further teaching. Touching the conjunctival sac with the eyedropper can introduce bacteria and lead to contamination or injury. The client should be advised to keep the dropper tip away from the eye to maintain sterility and safety.