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?

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

Tilt the client's head back when administering the medications.

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

Mix the medications with a semisolid food for the client.

Answer and Explanation

The Correct Answer is D

A. Place the medications on the back of the client's tongue:
Incorrect Explanation: Placing medications on the back of the tongue can increase the risk of choking and aspiration, especially in individuals with dysphagia.
Explanation: Individuals with dysphagia have difficulty swallowing and are at an increased risk of choking or aspirating (inhaling) substances into the lungs. Placing medications on the back of the tongue can be unsafe and is not recommended.
B. Tilt the client's head back when administering the medications:
Incorrect Explanation: Tipping the head back can worsen swallowing difficulties and increase the risk of choking or aspiration.
Explanation: Tipping the head back can compromise the natural swallowing mechanism and increase the risk of aspiration. It's important to keep the client's head in an upright position to aid safe swallowing.
C. Administer more than one pill to the client at a time:
Incorrect Explanation: Administering multiple pills at once can increase the risk of choking and aspiration, especially in individuals with dysphagia.
Explanation: Administering multiple pills at once can overwhelm the client's ability to swallow safely. This action can increase the risk of choking and aspiration, which is especially dangerous for individuals with dysphagia.
D. Mix the medications with a semisolid food for the client:
Correct Answer: This action is appropriate and safer for administering medications to an older adult client with dysphagia.
Explanation: Mixing medications with semisolid food, such as applesauce or yogurt, can help the client swallow more easily and reduce the risk of choking or aspiration. It's important to check with the healthcare provider or pharmacist to ensure that the medications can be mixed with food and that there are no interactions.

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Correct Answer is D

Explanation

A. Pallor:
Incorrect Explanation: While pallor (pale skin) can be a sign of an allergic reaction, it is not a specific indication of an allergic reaction to penicillin.
Explanation: Pallor can occur for various reasons, including shock or vasovagal responses, and it is not unique to allergic reactions.
B. Dyspepsia:
Incorrect Explanation: Dyspepsia (indigestion or upset stomach) is not a typical sign of an allergic reaction.
Explanation: Allergic reactions are more commonly associated with skin, respiratory, and cardiovascular symptoms, rather than gastrointestinal symptoms like dyspepsia.
C. Bradycardia:
Incorrect Explanation: Bradycardia (slow heart rate) is not a typical indicator of an allergic reaction.
Explanation: Allergic reactions generally do not directly cause bradycardia. Rapid heart rate (tachycardia) can be a symptom of an allergic reaction in some cases.
D. Urticaria:
Correct Answer: Urticaria (hives) is a common and characteristic sign of an allergic reaction, including to penicillin.
Explanation: Urticaria presents as raised, itchy, and often red welts on the skin. It is a classic manifestation of an allergic response and can occur rapidly after exposure to an allergen, including medications like penicillin.

A. The client's absolute neutrophil count was 2.500/mm³ before the medication was administered. B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered. C. The client had chemotherapy 12 hr before the medication was administered. D. The medication vial sat at room temperature for 2 hr before it was administered

Correct Answer is D

Explanation

A. The client's absolute neutrophil count was 2.500/mm³ before the medication was administered:
Incorrect Explanation: This is a normal data point that does not suggest an adverse event or error.
Explanation: An absolute neutrophil count of 2.500/mm³ is within the normal range, and there is no indication of a problem related to the administration of filgrastim based on this information.
B. The nurse flushed the client's IV line with dextrose 5% in water before and after the medication was administered:
Incorrect Explanation: Routine flushing of the IV line with appropriate solutions is a standard practice and not indicative of an incident.
Explanation: Flushing the IV line with dextrose 5% in water before and after medication administration is a routine procedure to maintain line patency and prevent interactions between medications.
C. The client had chemotherapy 12 hours before the medication was administered:
Incorrect Explanation: The timing of chemotherapy does not necessarily indicate an incident.
Explanation: Knowing the timing of chemotherapy is important for overall patient care, but it doesn't necessarily indicate an incident or error related to the administration of filgrastim.
D. The medication vial sat at room temperature for 2 hours before it was administered:
Correct Answer: This is the data point that should lead to filing an incident report.
Explanation: Many medications, including filgrastim, have specific storage requirements to ensure their effectiveness and safety. Allowing a medication vial to sit at room temperature for an extended period can compromise its stability and effectiveness. This situation should be reported as it involves a potential deviation from proper medication storage and handling procedures.

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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

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A nurse is preparing to administer the initial dose of penicillin G IM to a client. The nurse should monitor for which of the following as an indication of an allergic reaction following the injection?

Correct Answer is D

Explanation

A nurse recently administered filgrastim intravenously to a client who has cancer and is receiving cytotoxic chemotherapy. For which of the following data, discovered after the medication was administered, should the nurse file an incident report?

Correct Answer is D

Explanation

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