When a nurse assesses a client's ability to self-administer oral medications, which finding is most important to consider?
The client wants to take medications at a different time.
The client has mild nausea after taking the medication.
The client needs help reading the medication labels.
The client has difficulty swallowing the pills and tablets.
The Correct Answer is D
Rationale:
A. While a client’s preference to take medications at a different time is important for adherence, it does not directly impact the ability to safely self-administer oral medications. Scheduling can often be adjusted under the nurse’s guidance.
B. Mild nausea after taking medication is an adverse effect to monitor, but it may not prevent the client from taking medications safely. It can often be managed with supportive measures or timing adjustments.
C. Needing help reading medication labels is a barrier that can be addressed with large-print labels, medication organizers, or caregiver assistance. While it affects independence, it does not inherently prevent safe medication ingestion.
D. Difficulty swallowing pills and tablets is the most critical finding when assessing the ability to self-administer oral medications. This can directly compromise safety by causing choking, aspiration, or incomplete dosing. Identifying this issue allows the nurse to implement alternative strategies, such as using liquid formulations, pill crushers, or other administration techniques, to ensure the client receives the full prescribed dose safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"C"}
Explanation
Rationale:
- Chest tightness is correct for Blank 1 because this symptom may indicate a potentially life-threatening condition such as cardiac or respiratory compromise. Using the ABC priority framework, physiological stability and possible airway, breathing, or circulation issues must be addressed first.
- Anxiety is correct for Blank 2 because once immediate physiological threats are assessed, psychological distress should be evaluated. Anxiety can contribute to physical symptoms and may worsen chest discomfort.
- No appetite is correct for Blank 3 because while important, it is not an immediate threat to physiological stability. Appetite changes can be addressed after ruling out serious causes of chest tightness and evaluating anxiety.
Correct Answer is A
Explanation
Rationale:
A. Respiratory rate is the most important assessment before administering a medication that can cause respiratory depression, such as opioids or certain sedatives. These medications act on the central nervous system to reduce the drive to breathe, which can result in hypoventilation, decreased oxygenation, and, in severe cases, respiratory arrest. By assessing the client’s baseline respiratory rate, depth, and effort, the nurse can determine whether it is safe to administer the medication and establish a reference point for monitoring after administration. Identifying a low or irregular respiratory rate before giving the medication allows the nurse to intervene promptly, adjust the dose, or withhold the medication if necessary, ensuring patient safety.
B. Blood pressure is an important vital sign to monitor with many medications, as hypotension can be a side effect, especially with opioids. However, while low blood pressure may indicate hemodynamic instability, it is not the immediate risk associated with respiratory-depressant medications. Monitoring blood pressure is secondary to assessing respiratory function in this scenario.
C. Apical pulse rate is important for medications that affect cardiac function, such as antiarrhythmics or beta-blockers. While a slow or irregular heart rate can be concerning, it does not directly indicate the risk of respiratory depression, which is the primary safety concern with this type of pain medication.
D. Pain level assessment is necessary to determine the need for medication and to evaluate its effectiveness. However, assessing pain alone does not ensure safe administration. If a client is at risk for respiratory depression, giving medication without checking respiratory status could result in life-threatening complications.
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