The client is awake and alert when the nurse brings the oral medication to the client's room.
The nurse will:
With a gloved hand, place the pills in the client's mouth.
Hold the medicine cup to the lips and tip the pills into the client's mouth.
Ask the client if he or she wants to hold the medications in his or her hand.
Leave the medications on the breakfast tray for the client to take later.
The Correct Answer is C
Choice A rationale
Directly placing pills in a client's mouth with a gloved hand is generally not recommended as it can be perceived as invasive and may trigger the gag reflex, increasing the risk of aspiration. Client autonomy and active participation in medication administration are promoted for safety and adherence.
Choice B rationale
Tipping pills directly into a client's mouth can be problematic as it does not allow the client to assess the medication, potentially leading to discomfort or aspiration. It also bypasses the client's agency in the medication administration process, which is crucial for safety and compliance.
Choice C rationale
Offering the client the medication in their hand promotes autonomy and allows them to actively participate in the medication administration process. This approach respects client preferences, enhances safety by allowing self-administration, and facilitates the client's ability to examine the medication before ingestion, reducing the risk of errors.
Choice D rationale
Leaving medications unattended on a breakfast tray for later self-administration is a significant safety breach. This practice increases the risk of the medication being taken by another individual, loss or contamination, or incorrect timing of administration, potentially leading to adverse drug events. Direct observation of medication ingestion is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["167"]
Explanation
Step 1 is: Calculate the flow rate in mL per hour. (500 mg ÷ 500 mg) × 250 mL = 250 mL. (250 mL ÷ 90 min) × 60 min = 166.666. mL/hr. Rounded to the whole number, the flow rate is 167 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Assessing the client's skin for breakdown is important in general patient care, especially for immobile patients, but it is not a priority assessment directly related to the immediate physiological effects of administering an opioid analgesic like morphine. Skin integrity issues are typically a long-term complication.
Choice B rationale
Morphine, an opioid agonist, binds to mu-opioid receptors in the central nervous system, including the brainstem respiratory centers. This binding causes dose-dependent respiratory depression by decreasing the sensitivity of these centers to carbon dioxide, leading to reduced respiratory rate and depth. Normal respiratory rate is 12-20 breaths/min.
Choice C rationale
Opioids can cause urinary retention by increasing bladder sphincter tone and reducing detrusor muscle contractility, thereby impairing bladder emptying. While monitoring urinary output is important, respiratory depression is a more immediate and life-threatening adverse effect of opioid administration. Normal urinary output is 30-50 mL/hour.
Choice D rationale
Opioids commonly cause gastrointestinal side effects, including decreased gut motility, leading to constipation and reduced bowel sounds. While assessing abdominal sounds is relevant to monitor for ileus, respiratory depression poses a more acute and significant risk to patient safety following opioid administration.
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