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A nurse is providing teaching about managing anticholinergic effects for a client who has a new prescription for oxybutynin (Ditropan XL). Which of the following are appropriate to include in the teaching? Select all.
- A. Take frequent sips of water
- B. Wear sunglasses when exposed to sunlight
- C. Use a soft toothbrush when brushing teeth
- D. Take the medication with an antacid
- E. Urinate prior to taking the medication
Correct Answer: A, B, E
Rationale: The correct choices for managing anticholinergic effects of oxybutynin are A, B, and E. A: Taking frequent sips of water helps combat dry mouth, a common anticholinergic effect. B: Wearing sunglasses when exposed to sunlight helps with sensitivity to light, another anticholinergic effect. E: Urinating prior to taking the medication helps reduce urinary retention, a potential side effect.
Incorrect choices: C: Using a soft toothbrush is not directly related to managing anticholinergic effects. D: Taking the medication with an antacid may interfere with its absorption and is not recommended.
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A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 minutes. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
Correct Answer: 83
Rationale: To calculate the drip rate, we can use the formula: Drip rate = (Volume to be infused in gtt) / Time in minutes. In this case, the volume to be infused is 250 mL, and the time is 30 minutes. Convert 250 mL to drops: 250 mL x 10 gtt/mL = 2500 gtt. Now, divide 2500 gtt by 30 minutes to get 83.33 gtt/min. Since we can't administer a fraction of a drop, we round down to the nearest whole number, which is 83 gtt/min. This rate ensures the 0.9% NaCl solution is administered accurately over the specified time. Other choices are incorrect because they do not result from the correct calculation based on the given information.
A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?
- A. Registered dietitian
- B. Occupational therapist
- C. Physical therapist
- D. Social worker
Correct Answer: D
Rationale: The correct answer is D: Social worker. The social worker can help the older adult client access community resources such as meal delivery services, food assistance programs, or senior centers that provide nutritious meals. The social worker can also assess the client's social support system and address any other psychosocial needs that may impact his ability to prepare meals. Referring to a registered dietitian (choice A) may address the nutritional aspect but not the underlying social issues. Occupational therapists (choice B) focus on improving activities of daily living, physical therapists (choice C) focus on physical rehabilitation, which are not directly related to meal preparation difficulties.
A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention?
- A. Give the client thin liquids.
- B. Instruct the client to tuck her chin when swallowing.
- C. Have the client use a straw.
- D. Encourage the client to lie down and rest after meals.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to tuck her chin when swallowing. This intervention helps prevent aspiration by closing off the airway during swallowing, reducing the risk of food or liquids entering the lungs. Tucking the chin also helps direct the food or liquid down the esophagus. Giving thin liquids (choice A) can increase the risk of aspiration. Using a straw (choice C) may also increase the risk by bypassing the natural protective mechanisms. Encouraging the client to lie down after meals (choice D) can lead to aspiration due to decreased muscle tone and gravity assisting in food or liquid entering the airway.