Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Mix the medications with a semisolid food for the client.
Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.
B. Administer more than one pill to the client at a time.
Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.
C. Place the medications on the back of the client’s tongue.
Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.
D. Tilt the client’s head back when administering the medications.
ilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Pharmacology 2019 Proctored Exam. Take the full exam now
Full Explanation
The nurse should plan to take the following action:
A) Mix the medications with a semisolid food for the client.
Mixing the medications with a semisolid food, such as applesauce or pudding, can make it easier for an older adult client with dysphagia to swallow the medications safely. It helps in reducing the risk of choking and aspiration. This approach is typically used for clients who have difficulty swallowing pills.
Options B, C, and D are not recommended for a client with dysphagia:
B) Administering more than one pill at a time can increase the risk of choking and aspiration, which should be avoided.
C) Placing medications on the back of the client's tongue can also lead to difficulty swallowing and an increased risk of aspiration.
D) Tilting the client's head back when administering medications is not recommended as it can lead to aspiration. The head should be kept in a neutral position to support safe swallowing.
Similar Questions
A nurse is preparing to initiate IV therapy for a client.
Which of the following sites should the nurse use to place the peripheral IV catheter?
A. Dominant antecubital basilic vein.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
B. Nondominant dorsal venous arch.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
C. Dominant distal dorsal vein.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
D. Nondominant forearm basilic vein
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Full Explanation
This site is preferred for peripheral IV catheter placement because it is comfortable, has good blood flow, and has a lower risk of complications than the dominant arm or the antecubital fossa.
Choice A is wrong because the dominant antecubital basilic vein is more prone to dislodgement, thrombosis, and thrombophlebitis due to frequent movement of the elbow joint.
Choice B is wrong because the nondominant dorsal venous arch is a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
Choice C is wrong because the dominant distal dorsal vein is also a distal site that may have poor blood flow and higher resistance to infusion. It should be avoided unless there are no other options.
A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?
A. Bradycardia.
Choice Ais wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
B. Red man syndrome.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin. Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
C. Hypotension.
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
D. Hypoglycemia.
Choice Dis wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake. Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
Full Explanation
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
Choice A is wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.
Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
Choice D is wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who has infective endocarditis. Which of the following actions should the nurse take?
A. Discard the medication if it is yellow.
Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
B. Use a gravity flow set.
Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
C. Prime the tubing with 0.9% sodium chloride.
Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
D. Administer the medication over 2 hr.
Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.
Full Explanation
The correct answer is d. Administer the medication over 2 hr.
Choice A reason: Discarding the medication if it is yellow is not necessary. The color of amphotericin B lipid complex does not indicate its effectiveness or safety.
Choice B reason: Using a gravity flow set is not specifically required for the administration of amphotericin B lipid complex. Gravity infusion can be used to administer fluids and drugs where the rate is not critical and serious adverse effects are not anticipated. However, the use of a gravity flow set is not specifically mentioned in the guidelines for administering amphotericin B lipid complex.
Choice C reason: Priming the tubing with 0.9% sodium chloride is not recommended for amphotericin B lipid complex. This is because amphotericin B lipid complex is incompatible with saline solutions and should be diluted only with 5% dextrose injection. Priming the tubing is a common practice in IV therapy to remove air from the tubing before attaching it to the patient.
Choice D reason: Administering the medication over 2 hr is the correct action. Amphotericin B lipid complex is typically administered over a longer period, often 2-6 hours. This allows for a slow and steady delivery of the medication, which can help to minimize potential side effects.