The home health nurse assesses a client who takes oral medications daily at home. Which finding requires follow-up from the nurse?
The client chews their enteric-coated aspirin since they have difficulty swallowing it.
The client waits for their sublingual nitroglycerin to dissolve in their buccal cheek.
The client reviews their new prescription bottles to make sure the dosages are correct.
The client takes each pill one at a time until they are finished with their daily medications.
The Correct Answer is A
Rationale:
A. The client chewing their enteric-coated aspirin requires follow-up. Enteric-coated medications are specially formulated to dissolve in the intestine rather than the stomach to prevent gastric irritation and protect the medication from stomach acid. Chewing or crushing enteric-coated tablets destroys the protective coating, increasing the risk of stomach irritation, ulcers, or reduced effectiveness. The nurse should intervene and provide education on alternative options, such as discussing a different formulation with the healthcare provider.
B. Waiting for sublingual nitroglycerin to dissolve in the buccal cheek does not necessarily require follow-up. Although sublingual medications are typically placed under the tongue, allowing nitroglycerin to dissolve in the buccal area can still allow absorption through the oral mucosa. The key point is that the medication is not swallowed but allowed to dissolve for mucosal absorption.
C. Reviewing new prescription bottles to verify dosages is an appropriate and safe practice. This demonstrates medication awareness and helps prevent errors. No follow-up is required for this finding.
D. Taking each pill one at a time until finished is a safe medication practice. It reduces the risk of choking and helps ensure each medication is swallowed properly. This does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Peripheral neuropathy is a chronic condition often related to diabetes or nerve damage. While it may be associated with hypoxia in some cases, it is not an acute or immediate indicator of oxygen deprivation.
B. Pursed-lip breathing is a compensatory mechanism used by clients with respiratory distress or chronic lung disease to improve ventilation. It indicates the body is attempting to manage hypoxia but is not an emergency sign on its own.
C. Delayed capillary refill suggests poor peripheral perfusion, which can be concerning, but it reflects a localized or early sign of compromised circulation rather than severe hypoxia.
D. Central cyanosis is the most concerning finding. It indicates that oxygen saturation in the arterial blood is critically low, affecting vital organs. The presence of blue discoloration in the lips, tongue, or mucous membranes reflects significant hypoxemia and requires immediate assessment and intervention, such as oxygen therapy and evaluation of the underlying cause.
Correct Answer is A
Explanation
Rationale:
A. Comparing the new medication administration record (MAR) with the prescribed orders is the correct action. This verification ensures that all medications, doses, routes, and schedules are accurate and consistent with the provider’s current orders. It helps prevent errors that can occur during handoffs or transfers between units.
B. Assuming the orders are correct from the previous unit is unsafe. Transitions of care are high-risk periods for medication errors, and verification is essential regardless of the client’s stability or previous administration.
C. Skipping verification because the client is stable is incorrect. Stability does not guarantee that the orders are accurate. All new or transferred medication orders must be reviewed to prevent omissions, duplications, or incorrect dosages.
D. Administering medication based on the client’s request is unsafe. Clients may not have complete knowledge of their medications, doses, or schedules, and relying on their request can lead to errors. Nurses must verify orders with the MAR and prescriber instructions before administration.
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