A 70-year-old patient has just received a drug that can cause sedation.
What would be the priority nursing diagnosis for this patient?
Deficient Knowledge, unfamiliar with drug therapy.
Ineffective health maintenance, need for medication.
Risk for injury, related to adverse effect of the drug.
Noncompliance, cost of the drug.
The Correct Answer is C
Choice A rationale
This choice is incorrect. Although knowledge about drug therapy is important, it is not the most immediate concern in this scenario. The priority nursing diagnosis should address the potential risks associated with the drug’s side effects, such as sedation, which can impair the patient’s ability to function safely.
Choice B rationale
This choice is incorrect. While effective health maintenance and medication adherence are crucial, they do not directly address the immediate risk posed by the drug’s sedative effects. The priority should be to prevent harm and ensure the patient’s safety, which involves mitigating the risk of injury related to sedation.
Choice C rationale
This choice is correct. The primary concern with sedative drugs, especially in elderly patients, is the increased risk of falls and injuries due to impaired coordination and alertness. The nursing diagnosis “Risk for injury, related to adverse effect of the drug” directly addresses this critical issue, making it the priority in this situation.
Choice D rationale
This choice is incorrect. Noncompliance due to the cost of the drug is an important consideration, but it does not address the immediate safety risk posed by sedation. The priority should be to ensure the patient’s safety by managing the side effects that could lead to injury. Cost-related concerns can be addressed after ensuring that the patient is not at immediate risk of harm. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The auricle is an ear-shaped appendage on the surface of the atrium and does not separate the right and left halves of the heart. Its function is to increase the capacity of the atrium, allowing for more blood to be collected and passed to the ventricles.
Choice B rationale
Syncytia refer to a multinucleated cell that can result from the fusion of multiple cells, which is not a structure that separates the right and left sides of the heart. They are typically related to muscle tissue and coordinated contractions.
Choice C rationale
The Bundle of His is a collection of heart muscle cells specialized for electrical conduction that transmits the electrical impulses from the AV node to the point of the apex of the fascicular branches. It does not act as a separator between the right and left halves of the heart.
Choice D rationale
The septum is the structure that separates the right and left halves of the heart. It is a robust wall that divides the atria (interatrial septum) and the ventricles (interventricular septum), ensuring the segregation of oxygenated and deoxygenated blood.
Correct Answer is B
Explanation
Choice A rationale
Administering the medication even if the name of the drug can be clearly read is risky because the rest of the label might contain essential information like dosage, expiration date, and other critical instructions. Administering a medication without complete labeling increases the risk of medication errors.
Choice B rationale
Discarding the entire bottle and contents and obtaining a new bottle is the safest option. It ensures that the nurse is using a medication with a fully intact label, which includes all necessary information to safely administer the medication, such as dosage, route, and expiration date.
Choice C rationale
Asking another nurse to verify the contents of the bottle is not sufficient because the torn and soiled label still lacks complete information. Without all details, there's a risk of administering the wrong dosage or an expired medication.
Choice D rationale
Finding the drug information and making a new label for the bottle is not appropriate because it does not guarantee the accuracy of the dosage or other critical details that were on the original label. It's better to use a completely labeled and verified medication bottle.
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