A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Wash the tablet off with alcohol and place it in a clean medication.

Use the tablet's packaging to pick it up from the counter.

Discard the tablet and obtain another dose of medication.

Place the tablet directly into a medication cup.

Answer and Explanation

The Correct Answer is C

A.   Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B.   Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C.   Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D.   Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.

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Correct Answer is ["B","C","E"]

Explanation

A. Increased fiber in the diet is not a cause of constipation, but rather a preventive measure that can help promote regular bowel movements by adding bulk and softness to the stool.
B. Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of fecal matter in the colon, resulting in difficulty and pain during defecation.
C. Inadequate fluid intake is a cause of constipation, as it can contribute to dehydration and reduced stool moisture, making it harder and drier to pass.
D. Increased activity is not a cause of constipation, but rather a beneficial factor that can stimulate intestinal motility and facilitate bowel elimination.
E. Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependence, leading to decreased bowel tone and reduced peristalsis.

A. Observe client's respiratory status. B. Monitor intake and output every 8 hr. C. Elevate the head of the client's bed 30° to 45°. D. Check residual volume every 4 to 6 hr.

Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

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A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

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