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 D

Explanation

Choice A rationale

An absent pulse (0) indicates no palpable pulsation, often due to an occlusion or severe vasoconstriction. This signifies a complete lack of blood flow through the vessel, requiring immediate medical attention to prevent tissue ischemia and necrosis.

Choice B rationale

A bounding pulse (4+) is characterized by a strong, easily palpable pulsation that is not easily obliterated by pressure. This can indicate conditions like fluid overload, hypertension, or hyperkinetic states, reflecting increased stroke volume or decreased peripheral resistance.

Choice C rationale

A weak pulse (1+) is characterized by a faint, barely palpable pulsation that is easily obliterated by pressure. This can be indicative of decreased stroke volume, hypovolemia, or peripheral artery disease, signifying reduced blood flow and perfusion.

Choice D rationale

A normal pulse (2+) is characterized by a readily palpable pulsation that is easily discernible and not easily obliterated by pressure. This finding indicates adequate cardiac output and peripheral perfusion, signifying healthy cardiovascular function within normal physiological parameters.

A. 15 degrees. B. 90 degrees. C. 45 degrees. D. 30 degrees.

Correct Answer is A

Explanation

Choice A rationale

An intradermal injection is administered into the dermis, the layer of skin directly beneath the epidermis. A 15-degree angle ensures the needle enters superficially, creating a small wheal as the medication is deposited. This shallow angle minimizes penetration into subcutaneous tissue, which is crucial for proper antigen-antibody reactions in allergy testing or tuberculosis screening.

Choice B rationale

A 90-degree angle is used for intramuscular injections, where the medication is delivered deep into muscle tissue. This angle allows for rapid absorption due to the rich vascular supply of muscle, but it would cause excessive penetration and potential systemic absorption if used for an intradermal injection, negating its diagnostic purpose.

Choice C rationale

A 45-degree angle is typically used for subcutaneous injections, delivering medication into the adipose tissue layer beneath the dermis. This angle is too deep for an intradermal injection and would result in the medication being absorbed systemically rather than remaining in the dermal layer for localized diagnostic reactions.

Choice D rationale

A 30-degree angle is also too steep for an intradermal injection. While less deep than a 45-degree angle, it still risks penetrating beyond the dermis into the subcutaneous tissue. The goal of an intradermal injection is to deposit the substance within the highly specific dermal layer to elicit a localized, measurable response.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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