A nurse is administering oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?
"Let me check your medication order again."
"This is the medication that your doctor wants you to take."
"Let me explain the purpose of the medication."
"Sometimes the same pill comes in a different colour."
The Correct Answer is A
When a client expresses confusion or uncertainty about their medication, the nurse should always verify the medication order to ensure that the correct medication is being administered. Option (a) is the best response in this scenario because it addresses the client's concern and ensures the medication being given is the correct one.
Option (b) stating that "this is the medication that your doctor wants you to take" does not address the
client's concern and may cause the client to feel dismissed.
Option (c) suggesting to "let me explain the purpose of the medication" is not necessary at this time since
the client is already aware of the purpose and is only concerned about the colour of the pill.
Option (d) stating that "sometimes the same pill comes in a different colour" is not appropriate because it does not address the issue of the client's confusion about the current pill being administered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Sterile technique should ideally be used when handling the distal portion of the eyedropper to prevent introducing pathogens into the eye, as the eye is a sensitive area susceptible to infection.
B.When cleaning the eye, it is recommended to wipe from the inner canthus to the outer canthus to avoid bringing contaminants from the outer area closer to the tear duct, which reduces the risk of infection.
C.Applying pressure to the bridge of the nose is ineffective for preventing systemic absorption of the medication. Instead, pressure should be applied to the inner canthus (the nasolacrimal duct area) for about 1-2 minutes after instillation.
D.The correct technique for administering eye drops involves placing the prescribed number of drops into the conjunctival sac, not directly onto the cornea, as this can cause irritation and discomfort. Administering drops into the conjunctival sac allows for better absorption of the medication.
Correct Answer is B
Explanation
The correct answer is choiceb. Monitor the serum medication levels.
Choice A rationale:
Administering gentamicin with food is not necessary and does not minimize the risk of adverse effects. Gentamicin is typically given intravenously or intramuscularly, and food does not impact its administration or absorption.
Choice B rationale:
Monitoring the serum medication levels is crucial when administering gentamicin. Gentamicin has a narrow therapeutic index, meaning the difference between a therapeutic dose and a toxic dose is small. Regular monitoring helps ensure the drug remains within the safe and effective range, reducing the risk of nephrotoxicity and ototoxicity.
Choice C rationale:
Limiting the client’s fluid intake is not recommended. Adequate hydration is important to help prevent nephrotoxicity, a known adverse effect of gentamicin. Ensuring the client has sufficient fluid intake can help protect kidney function.
Choice D rationale:
Instructing the client to report agitation is not directly related to minimizing the risk of adverse effects of gentamicin. While it is important for clients to report any unusual symptoms, agitation is not a common adverse effect of gentamicin. Monitoring for signs of nephrotoxicity (e.g., decreased urine output) and ototoxicity (e.g., hearing loss, tinnitus) is more relevant.
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