Question

A nurse is preparing to administer enteric-coated aspirin to an older adult client who had a cerebrovascular accident and has difficulty swallowing medications. The client asks the nurse if she will crush the medication to make it easier to swallow. Which of the following responses should the nurse make?.

Answer 1

Correct Answers:

"If I crush it, you might experience a stomach ache or indigestion.”

Rationale :

🍽️ Enteric-coated aspirin is specifically formulated to bypass the stomach and dissolve in the intestines, reducing the risk of gastric irritation or ulcers—a common concern in older adults.

🍽️ Crushing the tablet destroys this protective coating, allowing the aspirin to irritate the stomach lining, which can cause pain, nausea, or bleeding.

🍽️ This response provides the most accurate and clear explanation to the client about why the medication should not be crushed, focusing on safety and comfort.

🍽️ For clients with swallowing difficulty, the provider should be consulted to order an alternative formulation, such as a liquid, chewable, or rectal suppository.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Albuterol.

Rationale :

🌬️ Albuterol is a short-acting beta2-agonist (SABA) and is the rescue inhaler of choice for acute asthma attacks.

🌬️ It works by rapidly relaxing bronchial smooth muscle, leading to quick bronchodilation and relief of wheezing, shortness of breath, and chest tightness.

🌬️ The nurse should instruct the child to always carry albuterol and use it at the first sign of an asthma exacerbation.

🌬️ Other medications listed—montelukast, fluticasone, and cromolyn—are maintenance drugs used for long-term control, not for immediate relief.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Serum potassium.

Rationale :

🧪 Furosemide is a loop diuretic commonly used to manage fluid overload in heart failure by promoting urine excretion.

🧪 A major concern with furosemide is hypokalemia (low serum potassium) due to increased renal excretion of potassium.

🧪 Low potassium levels can lead to muscle weakness, cramps, and life-threatening cardiac dysrhythmias, especially in clients with heart conditions.

🧪 The nurse should monitor serum potassium levels regularly, and the provider may prescribe potassium supplements or a potassium-sparing diuretic if needed.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Inform the provider of the client's potassium level.

Rationale :

⚠️ A serum potassium level of 5.8 mEq/L is above the normal range (typically 3.5–5.0 mEq/L) and indicates hyperkalemia, which can lead to life-threatening cardiac dysrhythmias.

⚠️ Administering potassium chloride when potassium is already elevated can worsen the condition and increase the risk of cardiac arrest.

⚠️ The nurse must withhold the potassium and immediately notify the provider for further orders, which may include stopping potassium supplements, adjusting medications, or initiating treatment for hyperkalemia.

⚠️ Prompt action is essential to prevent complications and ensure safe medication management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Down and outward.

Rationale :

👶 When administering eardrops to children under 3 years of age, the nurse should gently pull the auricle (pinna) down and outward.

👶 This action helps straighten the ear canal, allowing the medication to reach the inner parts of the external auditory canal more effectively.

👶 For children older than 3 years and adults, the correct technique is to pull the ear upward and outward.

👶 Using the proper method based on age ensures optimal drug delivery and minimizes discomfort during administration.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Heart failure.

Rationale :

❤️ Propranolol is a non-selective beta-adrenergic blocker used to treat hypertension, angina, arrhythmias, and migraines.

❤️ It works by reducing heart rate and myocardial contractility, which can worsen symptoms of heart failure, particularly in clients with decompensated or poorly controlled heart failure.

❤️ In clients with a history of heart failure, propranolol may reduce cardiac output too much, leading to fatigue, fluid retention, or exacerbation of heart failure symptoms.

❤️ The nurse should report this history to the provider before administration to ensure safe treatment and possibly select an alternative medication or adjust the dosage.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"I will sit on the side of the bed before I stand up.”.

Rationale :

🪑 Propranolol can cause orthostatic hypotension, especially when therapy is first initiated or the dose is adjusted.

🪑 Teaching the client to sit on the side of the bed before standing helps prevent dizziness, lightheadedness, and falls due to sudden drops in blood pressure.

🪑 This statement shows that the client understands how to manage a common side effect of the medication safely.

🪑 Monitoring for other beta-blocker effects like bradycardia, fatigue, and depression is also essential, but this answer best reflects understanding of safe self-care while taking the drug.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Peripheral edema of the ankles.

Rationale :

🦶 Nifedipine is a calcium channel blocker used to treat hypertension and angina by causing vasodilation and reducing peripheral resistance.

🦶 One of its common adverse effects is peripheral edema, especially in the ankles and lower legs, due to capillary fluid leakage from vasodilation.

🦶 If peripheral edema is present, it could indicate fluid retention or worsening cardiovascular status, and the provider should be notified for further evaluation or possible medication adjustment.

🦶 This side effect may warrant dose modification, adding a diuretic, or switching to an alternative antihypertensive agent.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

"A comprehensive list of medications is provided for the client at the time of discharge.”.

Rationale :

📋 Medication reconciliation is a formal process used to prevent medication errors by ensuring accuracy and continuity of a client's medication regimen across transitions in care.

📋 It involves creating a comprehensive and accurate list of all medications a client is taking — including prescribed, over-the-counter, and herbal supplements — and comparing it with new orders.

📋 A complete, updated list is provided at discharge to promote safe continuity of care and avoid omissions, duplications, or interactions.

📋 This list should be shared with the client and future care providers to ensure proper follow-up and safety.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Pull the pinna upward and backward.

Rationale :

👂 When administering ear drops to an adult, the correct technique is to pull the pinna (auricle) upward and backward.

👂 This action helps to straighten the external auditory canal, allowing the medication to reach deeper into the ear for maximum effectiveness.

👂 Using the correct technique improves absorption and comfort during administration.

👂 The nurse should also use clean (not sterile) gloves, warm the solution to room temperature, and may apply gentle pressure to the tragus unless contraindicated.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

2 :
A nurse is reinforcing teaching to a school-age child who has asthma. Which of the following medications should the nurse instruct the child to use to abort an ongoing attack?.

3 :
A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client?.

4 :
A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?.

5 :
A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?.

6 :
A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider?

7 :
A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?.

8 :
A nurse is collecting data from a client prior to administering nifedipine. For which of the following findings should the nurse contact the provider?.

9 :
A nurse is reviewing the components of medication reconciliation with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

10 :
The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?.

QLexNursing

2 : A nurse is reinforcing teaching to a school-age child who has asthma. Which of the following medications should the nurse instruct the child to use to abort an ongoing attack?.

3 : A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client?.

4 : A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?.

5 : A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?.

6 : A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider?

7 : A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?.

8 : A nurse is collecting data from a client prior to administering nifedipine. For which of the following findings should the nurse contact the provider?.

9 : A nurse is reviewing the components of medication reconciliation with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

10 : The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?.

2 :
A nurse is reinforcing teaching to a school-age child who has asthma. Which of the following medications should the nurse instruct the child to use to abort an ongoing attack?.

3 :
A nurse is caring for a client who is receiving furosemide to treat heart failure. Which of the following laboratory values should the nurse monitor for this client?.

4 :
A nurse is preparing to administer potassium chloride to a client who has a potassium level of 5.8 mEq/L. Which of the following actions should the nurse take?.

5 :
A nurse is preparing to administer eardrops to a 2-year-old child. The nurse should pull the auricle in which of the following directions when instilling the medication?.

6 :
A nurse is collecting data from a client who has hypertension and a prescription for propranolol. A history of which of the following conditions should be reported to the provider?

7 :
A nurse is reinforcing teaching with a client who has hypertension and is taking propranolol. Which of the following statements by the client indicates an understanding of the teaching?.

8 :
A nurse is collecting data from a client prior to administering nifedipine. For which of the following findings should the nurse contact the provider?.

9 :
A nurse is reviewing the components of medication reconciliation with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

10 :
The nurse is preparing to administer ear drops to an adult client. Which of the following actions should the nurse plan to take?.