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 C
Explanation
Choice A rationale
Pain sensation behind the eyes, particularly during palpation of the frontal or ethmoid sinuses, suggests inflammation or infection within these sinuses. Under normal conditions, healthy paranasal sinuses are air-filled cavities and should not elicit pain upon palpation.
Choice B rationale
Pain during palpation of any sinus area is indicative of sinusitis or inflammation. The presence of pain signifies pressure buildup, mucosal edema, or infection within the sinus cavities. Normal findings would not involve pain, but rather a sensation of mild pressure.
Choice C rationale
Normal findings during sinus palpation should elicit a sensation of pressure but no pain or tenderness. This indicates that the sinuses are air-filled, patent, and free from inflammation or congestion. The pressure is a result of the gentle digital compression over the bony structures.
Choice D rationale
Tingling along the nose and eyes is not a typical sensation associated with normal sinus palpation. This sensation might suggest neurological irritation, such as nerve compression or neuropathy, rather than a direct physiological response from the paranasal sinuses themselves.
Correct Answer is B
Explanation
Choice A rationale
Metabolism is primarily carried out by the liver, involving enzymatic biotransformation of drugs into more hydrophilic metabolites for excretion. While liver function can be impacted by systemic illness, renal failure's direct effect on drug metabolism is less significant than its impact on elimination. The liver's cytochrome P450 system typically remains functional.
Choice B rationale
Excretion is the primary elimination pathway for many drugs and their metabolites, mainly via the kidneys. In end-stage renal disease, glomerular filtration rate and tubular secretion are severely impaired, leading to accumulation of drugs and their toxic metabolites, necessitating dose adjustments or alternative elimination methods. Normal creatinine clearance is 80-120 mL/min.
Choice C rationale
Absorption refers to the movement of a drug from its administration site into the bloodstream. While renal failure can indirectly affect absorption through gastrointestinal changes (e.g., uremia-induced nausea), it is not the primary pharmacokinetic phase directly compromised by impaired kidney function. Bioavailability might be altered but not the fundamental absorption process.
Choice D rationale
Distribution involves the reversible movement of a drug from the systemic circulation into the interstitial and intracellular fluids. Renal failure can impact drug distribution due to fluid imbalances, altered protein binding (e.g., hypoalbuminemia), and changes in tissue perfusion, but it is not the most significant or direct pharmacokinetic impairment compared to excretion.
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