A nurse is planning to administer medications to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?

Administer more than one pill to the client at a time.

Tilt the client's head back when administering the medications

Place the medications on the back of the client's tongue

Mix the medications with a semisolid fop for the client

Answer and Explanation

The Correct Answer is D

A. Administer more than one pill to the client at a time: Administering more than one pill at a time may increase the risk of choking, especially for individuals with dysphagia. It's generally advisable to administer one medication at a time to ensure proper swallowing.
B. Tilt the client's head back when administering the medications: Tipping the head backward can increase the risk of aspiration (inhalation of medication into the airways). It is recommended to keep the head in a neutral or slightly forward position to facilitate swallowing.
C. Place the medications on the back of the client's tongue: Placing medications on the back of the tongue may trigger the gag reflex and increase the risk of aspiration. Medications should be placed on the front of the tongue to allow for better control and coordination of swallowing.
D. Mix the medications with a semisolid food for the client (Correct Answer): Mixing medications with a semisolid food, often referred to as "food thickening," can be beneficial for clients with dysphagia. This helps make the medications easier to swallow and reduces the risk of choking or aspiration. However, it is important to check with the healthcare provider or pharmacist to ensure compatibility with specific medications.

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Correct Answer is C

Explanation

A. The client's absolute neutrophil count was 2.500/mm before the medication was administered:
This information does not indicate an error in the administration process. The absolute neutrophil count being 2.500/mm before the medication was given is relevant to the client's condition but does not suggest an incident related to the administration of filgrastim.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Flushing the IV line with dextrose 5% in water is a standard practice before and after medication administration. This action helps ensure that the medication is effectively delivered and that the line remains patent. There is no indication of an error in this case.
C. The medication vial sat at room temperature for 2 hr before it was administered:
Filgrastim is a medication that typically requires refrigeration to maintain stability. Allowing it to sit at room temperature for an extended period can affect its efficacy and safety. This is a deviation from the recommended storage conditions and should be reported as an incident to assess potential consequences.
D. The client had chemotherapy 12 hr before the medication was administered:
This information does not necessarily suggest an incident related to the administration of filgrastim. The timing of chemotherapy is an essential consideration in cancer treatment protocols. Filgrastim is often administered to support recovery from the hematopoietic effects of chemotherapy.

A. Thready pulse B. Decreased bowel sounds C. Bilateral muscle weakness D. Distended neck veins

Correct Answer is D

Explanation

A. Thready pulse:
A thready pulse is more indicative of fluid volume deficit or inadequate cardiac output, not fluid volume excess.
B. Decreased bowel sounds:
Decreased bowel sounds are not a specific sign of fluid volume excess. They may be associated with various gastrointestinal issues but are not directly related to fluid volume status.
C. Bilateral muscle weakness:
Bilateral muscle weakness is not a specific manifestation of fluid volume excess. It may be associated with electrolyte imbalances or other neuromuscular issues.
D. Distended neck veins:
This is the correct answer. Distended neck veins are a classic sign of fluid volume excess or overload. Increased venous pressure from excess fluid can lead to distension of the jugular veins in the neck. This finding is often seen in conditions such as heart failure or renal failure where there is an inability to adequately excrete or distribute fluids.

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A nurse is planning to administer medications to an older adult client who has dysphagia. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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