When given a scheduled morning medication, the client states, "I haven't seen that pill before. Are you sure it's correct?" The nurse checks the medication administration record and verifies that it is listed. Which is the nurse's best response?

If you do not take it now, it will put you behind schedule."

Let me check the original order before you take it.

'It wouldn't be listed here if it were not ordered for you!"

It's listed here on the medication sheet, so you should

Answer and Explanation

The Correct Answer is B

A) "If you do not take it now, it will put you behind schedule.": While the nurse might be concerned about the medication schedule, this response dismisses the client's concern and doesn’t prioritize safety. The nurse should not pressure the client to take the medication before verifying that it is correct.
B) "Let me check the original order before you take it.": This is the best response because it demonstrates a commitment to patient safety. If the client is concerned about the medication, the nurse should take the time to verify the order directly from the original source to ensure the right medication is being given. This approach reassures the client and promotes trust.

C) "It wouldn't be listed here if it were not ordered for you!": This response can come across as dismissive and unprofessional. While it is important that the medication appears on the record, the nurse should still verify it to address the client's concern. Simply relying on the medication record without confirmation is not the best course of action.

D) "It's listed here on the medication sheet, so you should take it.": Similar to option C, this response dismisses the client’s concern and does not prioritize verifying the medication’s accuracy. It could lead to the client feeling their concerns were not taken seriously, which could negatively impact their trust in the care provided.

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Correct Answer is C

Explanation

A) Cerebral Vascular Accident (CVA): While a history of a CVA (stroke) is important to consider when prescribing medications, ondansetron is not contraindicated for clients with a history of CVA. The nurse would need to assess the client’s overall neurological status and risk factors but this condition is not an immediate concern for ondansetron use.

B) Depression: Ondansetron is not typically contraindicated in patients with depression. However, the nurse should be mindful of the potential for interactions with other medications the client may be taking for depression, but there is no direct contraindication between ondansetron and depression itself.

C) Glaucoma: This is the most concerning finding. Ondansetron can increase the risk of complications in clients with glaucoma, particularly narrow-angle glaucoma. Ondansetron has some serotonin receptor-blocking properties that can cause dilation of the pupil, which could increase intraocular pressure in clients with glaucoma. Therefore, this condition would require careful monitoring, and the nurse would need to consult with the healthcare provider before administering ondansetron to a client with glaucoma.

D) Congestive Heart Failure (CHF): While patients with CHF need to be monitored for fluid balance, ondansetron is not contraindicated in clients with CHF. The primary concern in these patients would be potential fluid retention or electrolyte imbalances, but this is generally not a direct concern for the administration of ondansetron itself.

A. Lying flat back B. Lying flat on stomach C. Left side lying D. Right side lying

Correct Answer is C

Explanation

A) Lying flat on the back: Positioning the client flat on their back is not the most effective position for administering a rectal suppository. The correct position allows for easier insertion and proper absorption of the medication. Lying flat on the back may make it difficult for the nurse to administer the suppository in the correct manner.

B) Lying flat on the stomach: Lying flat on the stomach is not recommended for the administration of a rectal suppository, as it can be uncomfortable for the client and can impede the ability to access the rectal area. The side-lying position is more effective for both client comfort and proper placement of the suppository.

C) Left side-lying: The left side-lying position, often referred to as the Sims' position, is the most appropriate for administering a rectal suppository. This position helps to expose the rectal area, allows for easier insertion, and promotes the suppository’s absorption, as gravity can assist in its positioning within the rectum.

D) Right side-lying: The right side-lying position is not as effective as the left side-lying position for the administration of a rectal suppository. The left-side position helps to ensure the smooth placement of the suppository and promotes its absorption. Therefore, the right side is not the optimal choice.

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Laboratory Test	Result	Normal Range
Sodium	146 mEq/dL	135-145 mEq/L
Calcium	8.2 mg/dL	8.4-10.2 mg/dL
Magnesium	1.2 mg/dL	1.6-2.2 mg/dL
Gastric pH	6	1-4

When given a scheduled morning medication, the client states, "I haven't seen that pill before. Are you sure it's correct?" The nurse checks the medication administration record and verifies that it is listed. Which is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is prescribed ondansetron for nausea. When reviewing the client's medical history, which finding would concern the nurse?

Correct Answer is C

Explanation

A client is ordered to receive a laxative by rectal suppository. How should the nurse position the client during the administration of the suppository?

Correct Answer is C

Explanation

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