Which intervention is most important for the nurse to implement when administering medications?

Elevate the head of the bed to at least 45 degrees.

Use at least two different methods to identify the client.

Provide a fresh glass of water for taking the medications.

Recheck the prepared medications against the medication administration record (MAR).

Answer and Explanation

The Correct Answer is B

A. Elevating the head of the bed is important for swallowing and preventing aspiration but is secondary to ensuring correct patient identification.
B. Using at least two different methods to identify the client is the most important step to prevent medication errors. This ensures that the correct medication is given to the correct patient.
C. Providing water is helpful but not as critical as ensuring the correct patient is identified.
D. Rechecking the medications against the MAR is important but should be done in conjunction with proper patient identification.

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Correct Answer is C

Explanation

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

A. Intranasal edema and swelling of turbinates. B. Purulent secretions from eyes and nares. C. Snoring and bilateral, pale gray nodules. D. Eye tearing and thick yellow nasal drainage.

Correct Answer is A

Explanation

A. Allergic rhinitis is characterized by intranasal edema and swelling of the turbinates due to inflammation caused by allergens. This is a common physical finding in clients with allergic rhinitis.
B. Purulent secretions typically indicate an infection rather than an allergic condition.
C. Bilateral, pale gray nodules might suggest nasal polyps, which are associated with chronic sinusitis rather than acute allergic rhinitis.
D. Eye tearing is common in allergic rhinitis, but thick yellow nasal drainage suggests an infection rather than an allergic reaction.

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Which intervention is most important for the nurse to implement when administering medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Correct Answer is A

Explanation

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