A nurse is administering an oral medication to an older adult patient. The patient states, “The pill I always take is green.
I don’t take an orange pill.”. What should the nurse respond?
“This is the medication that your doctor wants you to take.”.
“Sometimes the same pill comes in a different color.”.
“I will check your medication order again.”.
“Let me explain the purpose of the medication.”. .
The Correct Answer is C
Choice A rationale
Telling the patient that this is the medication their doctor wants them to take does not address the patient’s concern about the color of the pill.
Choice B rationale
While it’s true that the same medication can sometimes come in different colors, this response does not confirm that the orange pill is the correct medication for the patient.
Choice C rationale
Checking the medication order again is the best response. This will ensure that the patient is receiving the correct medication.
Choice D rationale
Explaining the purpose of the medication does not address the patient’s concern about the color of the pill.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
Correct Answer is B
Explanation
Choice A rationale
Phosphate levels are not directly affected by spironolactone. Spironolactone is a potassium- sparing diuretic and does not typically affect phosphate levels.
Choice B rationale
Decreased potassium level is not typically expected in a patient taking spironolactone. Spironolactone is a potassium-sparing diuretic, meaning it can actually lead to increased potassium levels. However, in the context of liver failure and ascites, other factors may influence potassium levels.
Choice C rationale
Chloride levels are not directly affected by spironolactone. Spironolactone primarily affects the balance of potassium and sodium in the body.
Choice D rationale
Sodium levels could potentially be decreased in a patient taking spironolactone, as it can cause the body to lose sodium. However, in the context of liver failure and ascites, sodium levels are often carefully managed.
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