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.

Answer and Explanation

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.

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Correct Answer is ["0.004"]

Explanation

Step 1 is: Convert mcg to mg. There are 1000 mcg in 1 mg.

Step 2 is: 4 mcg ÷ (1000 mcg/1 mg) = 0.004 mg. Answer: 0.004 mg.

A. We need to determine areas of tenderness before using percussion and palpation. B. It prevents distortion of bowel sounds that might occur after percussion and palpation. C. It allows the patient more time to relax and therefore be more comfortable with the physical examination. D. This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.

Correct Answer is B

Explanation

Choice A rationale

Determining areas of tenderness is typically done through palpation, which should follow auscultation to avoid altering bowel sounds. Performing palpation first could elicit guarding or muscle rigidity, making subsequent auscultation less accurate and potentially increasing patient discomfort.

Choice B rationale

Auscultation precedes percussion and palpation of the abdomen to ensure that bowel sounds are not artificially stimulated or inhibited. Mechanical manipulation of the abdomen through percussion and palpation can alter the frequency and character of bowel sounds, leading to inaccurate assessment of intestinal motility.

Choice C rationale

While patient comfort is important, the primary reason for the sequence of abdominal assessment is scientific accuracy. Manipulating the abdomen prior to auscultation can stimulate peristalsis, creating false-positive bowel sounds or increasing existing ones, thus obscuring the true baseline activity.

Choice D rationale

Distortion of vascular sounds like bruits and hums is less likely to be significantly affected by percussion and palpation compared to bowel sounds. Vascular sounds originate from blood flow dynamics, which are not as readily influenced by external mechanical manipulation as the peristaltic activity of the intestines.

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The client is awake and alert when the nurse brings the oral medication to the client's room. The nurse will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

4 mcg = mg (LABEL CORRECTLY)

Correct Answer is ["0.004"]

Explanation

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reasoning auscultation precedes percussion and palpation of the abdomen?

Correct Answer is B

Explanation

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The client is awake and alert when the nurse brings the oral medication to the client's room.
The nurse will: