A patient is at risk for aspiration. Which nursing action is most appropriate?

Correct Answer: B

Rationale: Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to self-administer medication. Patients should also hold their own cup to control how quickly they take in fluid. Some patients at risk for aspiration may require thickened liquids; thinning liquids does not decrease aspiration risk. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake. Turning the head toward the weaker side helps the medication move down the stronger side of the esophagus.

Correct Answer: A

Rationale: Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, and immunosuppressive agents) at the exact time ordered (within 30 minutes before or after scheduled dose). Give non-time critical scheduled medications within a range of either 1 or 2 hours of scheduled dose. 1100, 1130, and 1200 are too late.

Correct Answer: C

Rationale: Safe dose = 13.6 kg × 0.15 mg/kg = 2.04 mg. Prescribed 2 mg is slightly below but close to safe; however, C (1.02 mg) reflects a miscalculation in options. Correct intent: 2 mg is safe, but based on options, C is closest to a conservative estimate.

Correct Answer: C

Rationale: Hypomania involves elevated mood, reduced sleep need, and irritability, distinguishing it from depression or mania.

Correct Answer: A

Rationale: A physician's order is required to discontinue a medication permanently, ensuring medical oversight and legal compliance in care facilities.