#08 - Chapter 30: Medications

The nurse is to administer levothyroxine 0.125 mg PO at 0600. The package is labeled levothyroxine 125 mcg. Calculate the number of tablets the nurse will administer. Record your answer as a whole number.

1 tablet The nurse converts mg to mcg. 0.125 mg is equal to 125 mcg. The nurse will administer 1 tablet. Desired dose is 125 mcg. Dose on hand or supplied dose is 125 mcg. Quantity is 1 tablet.

The nurse has a prescription to administer 25 mg of furosemide IV to a client. The drug is supplied in a vial 40 mg/4 mL. How many mL will the nurse administer of the medication? Record your answer using one decimal place.

2.5 mL (25 mg/40 mg) x 4 mL 2.5 mL

The nurse has a prescription to administer 25 mg of furosemide IV to a client. the drug is supplied in a vial 40 mg/4 mL. How many mL will the nurse administer to the medication? Record your answer using one decimal place.

2.5 mL (25 mg/40 mg) x 4 mL = 2.5 mL

The nurse is administering morphine oral solution 5 mg to a client requesting medication for pain. The preparation is delivered as morphine solution 10 mg/5 mL. Calculate the amount, in mL, the nurse will administer. Record your answer to one decimal place.

2.5 mL The desired dose is 5 mg. The dose on hand or supplied dose is 10 mg. Quantitiy is 5 ml. The nurse would administer 2.5 ml. (5 mg/10 mg) × 5 ml = 2.5 ml

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client? A) 10 to 15 degrees B) 20 to 30 degrees C) 45 degrees D) 90 degrees

A) 10 to 15 degrees Intradermal injections are given at a 10- to 15-degree angle. Other answers are incorrect.

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug? A) 15-degree angle B) 45-degree angle C) 90-degree angle D) 120-degree angle

A) 15-degree angle A 15-degree angle is correct, as this allows the drug to be injected between the layers of the skin. A 45-degree angle is incorrect, as this will allow the drug to be injected beneath the skin but above the muscle. A 90-degree angle is incorrect, as this will allow the drug to be injected in the muscle. A 120-degree angle is incorrect, as this will be more suitable for intravenous injections.

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the MOST appropriate time to draw this blood? A) 1500 B) 1200 C) 2000 D) wait until day 5 of treatment

A) 1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.

The nurse is preparing to administer several prescribed medications to a client. The medications prescribed are to be given by the following routes: oral, subcutaneous, intramuscular, and intravenous. Place the routes in the proper order from SLOWEST to FASTEST absorption. Use all options 1. intramuscular (IM) 2. subcutaneous (SUBQ) 3. intravenous (IV) 4. oral (PO)

4. oral (PO) 2. subcutaneous (SUBQ) 1. intramuscular (IM) 3. intravenous (IV) Absorption is the process by which a medication enters the bloodstream. The route of administration affects how quickly and completely a medication is absorbed. Intravenous (IV) administration offers the quickest rate of absorption, followed in descending order by intramuscular (IM), subcutaneous, and oral (PO) routes.

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the MOST appropriate time to draw this blood? A) 1500 B) 1200 C) 2000 D) wait until day 5 of treatment

A) 1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.

A nurse is preparing to administer a rectal suppository to an adult client. How many inches (centimeters) should the nurse plan to insert the suppository? A) 3 in (7.5 cm) B) 1 in (2.5 cm) C) 2 in (5 cm) D) 5 in (12.5 cm)

A) 3 in (7.5 cm) A rectal suppository must make contact with the rectal mucosa for absorption to occur, so it should be inserted about 3 to 4 in (7.5 to 10 cm). Inserting the suppository 1 or 2 in (2.5 to 5 cm) will not make contact with the rectal mucosa and inserting it 5 in (12.5 cm) could affect the client's comfort level.

The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear? A) 5 minutes B) 10 minutes C) 15 minutes D) 20 minutes

A) 5 minutes When ear drops are to be administered in both ears, the nurse would wait 5 minutes after giving the ear drops in the first ear before administering the ear drops into the second ear. This avoids causing the medication to run out immediately after administration. Other times are longer than are needed between ears.

Which client does the nurse recognize will require an intramuscular administration of the medication instead of an intravenous administration A) client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination B) client who is beginning treatment with chemotherapy following a diagnosis of ovarian cancer C) client who is diagnosed as having sepsis and is prescribed antibiotic therapy D) client who is in the emergent phase of a 50% partial-thickness (second-degree) burn and requiring medication for pain

A) a client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination The hepatitis B vaccine is administered intramuscularly. Recombivax HB, a form of the hepatitis B vaccine, may be administered subcutaneously to clients who are at high risk for hemorrhage. This client is low risk. Medications for the clients experiencing the situations listed would be administered intravenously.

To which client would the nurse be most likely to administer a PRN medication? A) a client who is reporting pain near the surgical site B) a client who requires daily medication to control hypertension C) a client who is experiencing severe and unprecedented chest pain D) a client whose asthma is treated with inhaled corticosteroids

A) a client who is reporting pain near the surgical site A report of "breakthrough" pain, especially postsurgery, would likely require the nurse to administer a PRN analgesic. A new onset of chest pain would likely require a stat order, while longstanding treatment of hypertension and asthma would likely include standing orders for relevant medications.

The nurse is preparing to administer a bolus of an intravenous medication. How should the medication be administered? A) all at once B) over 3 hours C) in tandem with another medication D) over the duration of a 12-hour shift

A) all at once Bolus administration is given into a vein all at one time. All other answers are incorrect.

The nurse is preparing to administer a bolus of an intravenous medication. how should the medication be administered? A) all at once B) over 3 hours C) in tandem with another medication D) over the duration of a 12-hour shift

A) all at once Bolus administration is given into a vein all at one time. All other answers are incorrect.

An oral medication has been ordered for a client who has a nasogastric tune in place. Which nursing activity would increase the safety of medication administration? A) check the tube placement before administration B) have the client swallow the pills around the tube C) flush the tube with 30 to 40 mL saline before medication administration D) brings the liquids to room temperature before administration

A) check the tube placement before administration The nurse must first verify that the tube is in place and not in the lungs prior to administering the medication. Next, the nurse can bring the liquids to room temperature. Typically the tube is flushed with 15 to 30 mL of water for adults (5 to 10 mL for children). The nurse should never have the client swallow the pills if the client has an nasogastric tube.

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection? A) checking for documented allergies to food or drugs B) preparing the syringe with the medication C) cleaning the area with an alcohol swab D) gathering all the equipment needed

A) checking for documented allergies to food or drugs Checking for documented allergies to food or drugs is done to ensure safety and is therefore correct. Preparing the syringe with the medication is incorrect because this is considered planning, not assessment. Cleaning the area with an alcohol swab is implementing, not assessing. Gathering all the equipment needed is also considered planning.

The nurse is preparing to perform venipuncture to insert a peripheral IV catheter in an adult client. Which action should the nurse perform? A) cleanse the site with an application of 5% chlorhexidine in 70% isopropyl alcohol B) apply sterile gloves before inserting the intravenous device C) place a cold cloth over the intended site for greater access D) place a tourniquet 2 inches (5 cm) below the selected site

A) cleanse the site with an application of 5% chlorhexidine in 70% isopropyl alcohol The site should be cleansed with the site with an application of 5% chlorhexidine in 70% isopropyl alcohol. The nurse should place a tourniquet or blood pressure cuff on the extremity 4 to 6 inches (10 to 15 cm) above the intended venipuncture site. Gloves are required but these do not need to be sterile. A cold cloth would make veins harder to access, due to vasoconstriction.

The nurse is preparing to administer a client's intramuscular injection and intends to use the technique shown. What potential benefit of this technique should the nurse desribe? A) decreased irritation and pain in subcutaneous tissue B) less frequent administration of the medication C) more rapid administration of the medication D) decreased risk for infection

A) decreased irritation and pain in subcutaneous tissue This technique is Z-tracking. The Z-track technique allows the medication to be administered into the muscle tissue with no tracking of medication in the subcutaneous tissues as the needle is removed, resulting in less pain and irritation.

The nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration? A) deltoid B) vastus lateralis C) ventrogluteal D) scapula

A) deltoid The deltoid is the best site for this medication. Biologicals for infants and young children are administered at the vastus lateralis. The ventrogluteal site is used for depot formulations and irritating medications. The scapula is a site for an intradermal injection.

There have been an increase of needlestick injuries in the intensive care unit. When preparing to address this occurrence in a staff meeting, what should the nurse manager include in an education presentation to prevent needlestick injuries? Select all that apply. A) disposing of used needles in sharps container B) recapping all needles after use C) using self-retracting safety needles D) wearing gloves for performing venipuncture E) using needleless adapter for medication administration

A) disposing of used needles in sharps container C) using self-retracting safety needles E) using needleless adapters for medication administration To avoid needlestick injuries, the nurse should dispose of needles in appropriate sharps containers, should not attempt to recap needles, and should utilize self-retracting safety needles when performing venipuncture. Use needleless adapters whenever possible for all other IV maintenance and medication administration. Although observing Standard Precautions limits provider exposure to bloodborne pathogens, especially hepatitis B and HIV, gloves do not help to avoid needlestick injuries.

A client is being started on total parenteral nutrition (TPN). When initiating the therapy, the nurse gradually taper up the infusion rate as ordered to prevent which potential complication? A) hyperglycemia B) infection C) air embolism D) pneumothorax

A) hyperglycemia Metabolic complications also may present a problem for the client receiving TPN. Most commonly, clients experience hyperglycemia if they are unable to tolerate the high glucose content of the TPN solution. When therapy is initiated, the infusion rate is usually tapered up over a period of a day or two. Using strict aseptic technique during catheter manipulations, dressing changes, and tubing and bottle changes helps to reduce the risk for infection. Air embolism and pneumothorax are potential complications that are associated with central line placement, not TPN administration.

The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication? A) in the anterolateral aspect of the thigh B) in the lateral aspect of the upper arm C) in the lower abdomen D) in the gluteus maximus muscle in the buttocks

A) in the anterolateral aspect of the thigh The vastus lateralis site is in the anterior aspect of the thigh, in which the nurse places the injection in the middle third of the thigh and is often used for infants. Therefore, this description is correct. The deltoid site is located in the lateral aspect of the upper arm. The dorsogluteal site is located in the gluteus maximus muscle in the buttocks.

A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation? A) medications that need to be infused over 20 to 60 minutes B) medications that are given over 1 minute for rapid therapeutic effect C) medications that can be given through a capped intravenous port D) medications that are toxic if given over short periods

A) medications that need to be infused over 20 to 60 minutes Intermittent infusions are used for medications that need to be administered for an intermediate length of time, usually 20 to 60 minutes. The intravenous push technique is used for medications that can be given over 1 minute for rapid therapeutic effect, and may be given into a continuously infusing IV set or into a capped IV port. The continuous infusion technique is used for medications that are toxic if given over short periods.

The nurse is preparing to apply nitroglycerin paste. After checking the order, washing hands, checking the client's identity, and applying gloves, which is the NEXT nursing action? A) removing prior application and any remaining residue from skin B) covering application paper with plastic with transparent semipermeable dressing C) squeezing prescribed amount of paste from tube onto application paper D) using wooden applicator to spread paste over the paper

A) removing prior application and any remaining residue from the skin The nurse will remove one application and residue before applying another, as this prevents excessive drug levels when a new application is placed. The nurse will then proceed to squeeze the paste onto the paper, spread the paste over the paper, apply the paper, and cover it with a transparent semipermeable dressing.

A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be MOST appropriate? A) select another site B) apply a warm compress for 5 minutes C) loosen the tourniquet slightly D) apply a topical anesthetic

A) select another site If a vein appears hard or ropelike, the nurse should select another spot for the venipuncture. Applying a warm compress would be used to help dilate the vein. Loosening the tourniquet would have no effect on the "hardness" of the vein. The vein should not be used. Applying a topical anesthetic is appropriate to reduce the pain associated with insertion. However, a vein that feels hard should not be used.

When instructing the client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug? A) swallowing the medication B) taking the medication on an empty stomach C) talking when taking the medication D) performing physical activities

A) swallowing the medication When administering medication by sublingual application, the client should avoid swallowing or chewing the medication. Eating or smoking during administration is also contraindicated. Taking the medication on an empty stomach, talking, or performing physical activities may not be contraindicated when administering drugs sublingually.

The nurse is preparing to administer a mediation to a client when the client states, "Last time I took that mediation, I broke out in hives." What is the priority action by the nurse? A) withhold the medication and notify the health care provider that ordered the medication B) administer the medication, the reaction may not occur again C) administer the mediation and monitor the client for 30 minutes after administration D) substitute another medication with the same action

A) withhold the medication and notify the health care provider that ordered the medication Whenever a client reports being allergic to a medication, the nurse should withhold the medication and notify the provider so that something else may be ordered. The medication should never be administered due to the risk of a potential anaphylactic reaction. The nurse may not substitute any medication without a providers order.

The nurse correlates the metric system as the MOST accurate method utilized to administer medications for which reason? A) the dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements B) it uses a system based on household measurements which are easily understood and measured C) it prevents error by never using leading zeros for doses less than one measurement unit D) it ensures accuracy by expressing quantities in fractions and Arabic numbers

A) the dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements The metric system is the most widely accepted and convenient system of measurement for drug administration and the strength and frequency of the dose also are indicated (e.g., digoxin 0.125 mg daily). The system is measured by 10s and can easily be consistently converted to other increments; i.e. .25 m = 25 cm = 250 mm. A recommended mistake-proofing practice when administering medications using the metric system is never to use trailing zeros (e.g., 5 mg, never 5.0 mg); using trailing zeros increases the likelihood of an error. A mistake-proofing practice is to always use leading zeros for doses less than one measurement unit (e.g., 0.3 mg, never .3 mg); it does not prevent errors by omitting leading zeros. The metric system does not utilize fractions and Arabic numbers and is not based on commonly used household measurements.

The nurse correlates the metric system as the MOST accurate method utilized to administer medications for which reason? A) the dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements B) it uses a system based on household measurements which are easily understood and measured C) it prevents errors by never using leading zeros for doses less than one measurement unit D) it ensures accuracy by expressing quantities in fractions and Arabic numbers

A) the dosage prescriptions of medications most often use this system as it is measured in 10s and can be easily converted between measurements The metric system is the most widely accepted and convenient system of measurement for drug administration and the strength and frequency of the dose also are indicated (e.g., digoxin 0.125 mg daily). The system is measured by 10s and can easily be consistently converted to other increments; i.e. .25 m = 25 cm = 250 mm. A recommended mistake-proofing practice when administering medications using the metric system is never to use trailing zeros (e.g., 5 mg, never 5.0 mg); using trailing zeros increases the likelihood of an error. A mistake-proofing practice is to always use leading zeros for doses less than one measurement unit (e.g., 0.3 mg, never .3 mg); it does not prevent errors by omitting leading zeros. The metric system does not utilize fractions and Arabic numbers and is not based on commonly used household measurements.

Which statement BEST describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection? A) the ventrogluteal site provides a location with the capacity for depositing and absorbing the drug B) the ventrogluteal site determines whether or not the needle is in a blood vessel C) the ventrogluteal site prevents tissue contact with the irritating drug D) the ventrogluteal site reduces the transmission of microorganisms

A) the ventrogluteal site provides a location with the capacity for depositing and absorbing the drug The ventrogluteal site is a large muscular injection site that provides a location with the capacity for depositing and absorbing the drug and is therefore correct. The nurse will reduce the transmission of microorganisms by hand washing and not by selecting the ventrogluteal site. The nurse will aspirate for a blood return to determines whether or not the needle is in a blood vessel. Changing the needle will prevent tissue contact with the irritating drug, not the usage of the ventrogluteal site.

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity? A) therapeutic range B) peak level C) trough level D) half-life

A) therapeutic range Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. Peak level is the highest plasma concentration. Trough level is the point when the drug is at the lowest concentration. Half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

What is the BEST explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal? A) to determine the extent to which the client responded to the drugs B) to administer timely emergency treatment C) to implement measures to reduce the transmission of microorganisms D) to prevent interfering with test results

A) to determine the extent to which the client responded to the drugs Determining the extent to which the client has responded to the drugs is correct, as this allows the nurse to observe the area for signs of local reaction in which the standard time is 24-48 hours. Ensuring that emergency treatment is quickly administered is incorrect since the nurse is to observe the client for allergy to the test in the first 30 minutes. Reducing the risk for the transmission of microorganisms is incorrect since this could be achieved by the nurse removing gloves and performing hand hygiene immediately after administering the drug. Preventing interference with test results is incorrect, as the nurse could instruct the client not to rub the area.

A client requests more medication for pain at the surgical site rated 8 out of 10. There is a PRN prescription for 10 mg PO of oxycodone for pain greater than 6 out of 10 on the pain scale. Which action should the nurse take FIRST? A) verify clients name and date of birth B) administer the prescribed amount of oxycodone C) review file for adverse effects D) determine if the prescription is appropriate

A) verify clients name and date of birth The nurse administers prn prescriptions "as needed," based on the time frame and directions prescribed by the provider. However, the first step is to have the client verify their name and date of birth. Determining if the prescription is appropriate as well as reviewing for adverse effects are done prior to initiating therapy of the drug, not when the client has been taking the medication.

The nurse is preparing to administer a medication to a client when the client states, "Last time I took that medication, I broke out in hives." What is the priority action by the nurse? A) withhold the medication and notify the health care provider that ordered the medication B) administer the medication, the reaction may not occur again C) administer the medication and monitor the client for 30 minutes after administration D) substitute another medication with the same action

A) withhold the medication and notify the health care provider that ordered the medication Whenever a client reports being allergic to a medication, the nurse should withhold the medication and notify the provider so that something else may be ordered. The medication should never be administered due to the risk of a potential anaphylactic reaction. The nurse may not substitute any medication without a providers order.

The nurse is preparing to administer a medication to a client when the client states, "Last time I took the medication, I broke out in hives." What is the priority action by the nurse? A) withhold the medication and notify the health care provider that ordered the medication B) administer the medication, the reaction may not occur again C) administer the medication and monitor the client for 30 minutes after administration D) substitute another medication with the same action

A) withhold the medication and notify the health care provider that ordered the medication Whenever a client reports being allergic to a medication, the nurse should withhold the medication and notify the provider so that something else may be ordered. The medication should never be administered due to the risk of a potential anaphylactic reaction. The nurse may not substitute any medication without a providers order.

What is the BEST response by the nurse when a client asks about the side effects of using nasal spray? A) "Long-term use a nasal sprays can cause difficulty in coordinating breathing B) "Long-term use of nasal sprays can cause rebound nasal congestion C) "Long-term use of nasal sprays can repair the nasal passage D) "Long-term use of nasal sprays can cause an unpleasant taste

B) "Long-term use of nasal sprays can cause rebound nasal congestions Saying that long-term use of nasal sprays can cause rebound nasal congestion is correct, as this usually occurs when nasal sprays are used repeatedly by clients. Long-term use of nasal sprays cannot cause difficulty in coordinating breathing; this is more applicable with inhalers than with nasal sprays. Long-term use of nasal sprays do not repair the nasal passage; instead, they damage the nasal passage. Long-term use of nasal sprays does not cause an unpleasant taste; this is more appropriate with inhalers and not nasal sprays.

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response? A) "This is to decrease the amount of drug that you receive B) "Medication stays in the chamber so you can continue to inhale it C) "You will receive the medication faster as it goes through this device D) "It makes the inhaler easier to hold incase you have arthritis

B) "Medication stays in the chamber so you can continue to inhale it." A spacer provides a reservoir for aerosol medication. The client can take additional breaths (after the initial breath) to continue inhaling the medication held in the reservoir. The spacer does not decrease the amount of medication received, make the medication move faster, or serve as a holding device.

The nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? A) standing order B) PRN order C) one-time order D) stat order

B) PRN order A PRN order is one that is given to a client on an "as needed" basis.

To convert 0.8 grams to milligrams, the nurse should do which of the following? A) move the decimal point 2 places to the right B) move the decimal point 3 places to the right C) move the decimal point 2 places to the left D) move the decimal point 3 places to the left

B) move the decimal point 3 places to the right To convert a larger unit into a smaller unit, move the decimal point to the right (the new number is larger than the original). 1000 milligrams (mg) is equal to 1 gram (g); therefore 0.8 g is multiplied by 1000 (which is equivalent to moving the decimal point 3 places to the right) to determine how many mg it is equivalent to.

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss? A) a larger syringe is required when giving an intramuscular injection on an obese person B) as the gauge number becomes larger, the diameter of the needle and the lumen become smaller C) when giving an injection, the amount of the medication directs the choice of gauge D) the size of the syringe is directed by the viscosity of the medication to be given

B) as the gauge number becomes larger, the diameter of the needle and the lumen become smaller The larger the gauge, the smaller the needle. An obese person requires a longer needle to reach muscle tissue than does a thin person. When giving an injection, the viscosity of the medication directs the choice of needle gauge. The size of the syringe is directed by the amount of the medication to be given.

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply. A) Tell Client A that the wrong drugs were given to Client B B) assess Client B thoroughly C) do nothing as long as Client B has no reaction D) complete an incident report E) contact the provider to report the error

B) assess Client B thoroughly D) complete an incident report E) contact the provider to report the error The nurse will assess and monitor Client B, complete an incident report, and notify the provider in case other orders may need to be given. It is ethically and legally inappropriate to refrain from taking action. Telling Client A about the error violates HIPAA.

A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client? A) continuous drip B) bolus administration C) gravity infusion D) electronic infusion device

B) bolus administration A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.

The nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client? A) continuous drip B) bolus administration C) gravity infusion D) electronic infusion device

B) bolus administration A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump.

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client: A) takes rapid, shallow breaths until the medication is complete B) breathes through his or her mouth until all the medication has been inhaled C) coughs intermittently while the medication is being administered D) rinses his or her mouth with water before the medication is administered

B) breathes through his or her mouth until all the medication has been inhaled The client should breathe through his or her mouth rather than through the nose. It is not necessary to rinse before administration or to cough during administration. Deep breathing is preferable to shallow breathing because this improves absorption.

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the MOST appropriate site for administration? A) vastus lateralis B) deltoid C) biceps brachii D) scapula

B) deltoid The deltoid and ventrogluteal sites are more appropriate for adults than the vastus lateralis. The scapula is a site for an intradermal injection. The biceps brachii muscle is not used for intramuscular injections.

The charge nurse is observing a new nurse administer an intramuscular (IM) medication to an adult client for the first time. After reviewing the image, what should the charge nurse do next? A) stop the new nurse from administering the medication B) inform the new nurse to spread the fingers outward to visualize landmarks for the injection C) instruct the new nurse to continue with the medication administration using the current technique D) tell the new nurse to move aside, so another nurse can safely administer the medication using this route

B) inform the new nurse to spread the fingers outward to visualize landmarks for the injection The nurse's hand is too close to the injection site and in the wrong position, which can alter appropriate visualization of the correct location to inject the medication. The nurse should use the index finger and thumb to locate the correct position. There is a higher likelihood the nurse can injure him- or herself performing this technique. Ensuring the needle is darted into the appropriate location through proper visualization can minimize needle stick injuries.

Which is an accurate guideline for client teaching regarding the use of a dry powder inhaler (DPI)? A) instruct the client not to directly touch the mouthpiece B) instruct the client that if mist can be seen from the mouth or nose, the DPI is being used incorrectly C) instruct the client not to eat or drink for 30 minutes after use D) instruct the client to breathe in slowly with shallow breaths, over 2 to 3 seconds

B) instruct the client that if mist an be seen from the mouth or nose, the DPI is being used incorrectly A mist should not be seen coming from the client's mouth or nose. The client should touch the mouthpiece directly and should breathe in quickly and deeply through the mouth, over 2 to 3 seconds.

The nurse is educating a client on how to self-administer subcutaneous insulin injections. The client asks why the needle must be removed at the same angle as that of insertion. How will the nurse respond? A) this verifies correct injection of the drug B) it minimizes tissue trauma C) it prevents needlestick injuries D) this helps to control placement of the needle

B) it minimizes tissue trauma Removing the needle at the same angle at which it was inserted to administer medication minimizes tissue trauma and discomfort to the client. To verify correct injection of the drug, the client will push the plunger and watch for a small wheal. To prevent needlestick injuries, the client will cover the needle with a protective cap. Holding the arm still and stretching the skin taut helps to control placement of the needle.

The nurse is reviewing a medication prescription for a client prior to administration and observes that the route of administration is not present in the prescription. What is the appropriate action by the nurse to address this omission? A) add the route to the prescription and administer the medication since the nurse is familiar with the drug B) notify the health care provider to add the route and then administer the medication when complete C) call to ask the pharmacy how the drug should be administered D) omit the administration of the medication since it was written incorrectly

B) notify the health care provider to add the route and then administer the medication when complete The nurse should notify the health care provider and should refrain from administering the medication until the missing information is obtained. The nurse should not implement a questionable medication prescription until after consulting with the person who has written the prescription. The nurse should not omit the medication without consulting with the provider that prescribed it, because the client will not receive the therapeutic benefits. The pharmacy cannot determine the correct route, because the prescription must come from the prescriber.

When administering oral medication, which practices should the nurse follow? Select all that apply A) dispense multiple liquid medications into a single cup to reduce the number of containers the client must handle B) perform hand hygiene before and after medication administration C) stay at the bedside until the client has swallowed all the medications D) store the client's MAR at the bedside at all times to ensure safe identification E) verify the client's response to the medication 30 minutes after administration or as appropriate for the drug

B) perform hand hygiene before and after medication administration C) stay at the bedside until the client has swallowed all the medications E) verify the client's response to the medication 30 minutes after administration or as appropriate for the drug When administering oral medications, it is important to perform hand hygiene before and after administration and to stay with the client until all medications have been swallowed. The nurse should also assess the effect of the medication at a reasonable time after administration. The MAR should be brought to the bedside to verify the client, but it is not left at the bedside. It would be inaccurate and unsafe to dispense multiple liquid medications into a single cup, as this may result in dosage errors.

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method? A) a container with enough prescribed medications for several days for a client B) self-contained packets that hold one tablet or capsule for individual clients C) a supply that remains on the nursing unit for use in an emergency D) systems that contain frequently used medication for that unit

B) self-contained packets that hold one tablet or capsule for individual clients The nurse should understand that a unit dose supply method is a method in which self-contained packets hold one tablet or capsule for an individual client. An individual supply is a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay. Some facilities use automated medication-dispensing systems, which contain frequently used medications for that unit, any as-needed (PRN) medications, controlled medications, and emergency medications.

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this upcoming dose of scheduled unit-dose packaged antihypertensive medication? A) place the dose in the medication cup with other medications B) set the antihypertensive dose aside pending assessment C) ask the client to report any dizziness and lightheadedness D) teach the client to use the call bell whenever getting out of bed

B) set the antihypertensive dose aside pending assessment Knowing that the previous dose was held, the nurse sets the antihypertensive aside until an assessment of current blood pressure is performed or verified. The nurse scans and administers all the regularly scheduled medications at one time, except for those requiring additional assessment. Those unit-dose packages are set to the side until the nurse is sure that administration is the correct action. The client should already know to call for assistance, if needed, and to report new or worsening symptoms, such as feeling dizzy.

A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection? A) sites commonly used for a subcutaneous injection are the inner surface of the forearm and the upper back, under the scapula B) subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis C) subcutaneous injections are administered at a 30 to 45 degree angle based on the amount of subcutaneous tissue parent D) pinching is advised for obese clients to lift the adipose tissue away from underlying muscle and tissue

B) subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. Sites commonly used for an intradermal injection are the inner surface of the forearm and the upper back, under the scapula. Various sites may be used for subcutaneous injections, including the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crests), the anterior aspects of the thigh, the upper back, and the upper ventrogluteal area. Subcutaneous injections are administered at a 45- to 90-degree angle, based on the amount of subcutaneous tissue present and the length of the needle. Pinching is advised for thinner clients and when a longer needle is used, to lift the adipose tissue away from underlying muscle and tissue.

The nurse is preparing to administer nasal medication via a dropper to a client with severe congestion. Into which position will the nurse place the client? A) prone B) supine C) oblique D) lithotomy

B) supine To best facilitate instillation of nasal medication via a dropper, and to ensure that the drug is administered into the place where its effects are desired, the nurse will place the client in supine position. The other positions are not appropriate.

Which component of a syringe's needle does the nurse recognize that refers to width? A) lumen B) shaft C) bevel D) gauge

D) gauge The gauge of a needle refers to width. The lumen is the opening of the needle; the shaft is the length of the needle; the bevel is the slanted portion of the needle that provides access into the vein.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a non-emergent client situation. What is the nurse's appropriate response? A) input the order into the computerized provider order system B) tactfully request the provider to input the order into the computerized provider order system C) refuse to implement the order and notify the nurse manager D) have another nurse witness and record the order into the medication administration record (MAR)

B) tactfully request the provider to input the order into the computerized provider order system Providers are to enter their own orders when they are physically present. It is appropriate for the nurse to tactfully request that the provider do so. The nurse should not input the order, nor refuse to implement it.

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler? A) the nurse should instruct the child to prolong her/her inhalation B) the nurse should use a nebulizer to administer the medication C) the nurse should assess the child's mucous membranes D) the nurse should provide simple written instructions

B) the nurse should use a nebulizer to administer the medication The nurse's use of a nebulizer to administer the medication is correct, as this is an alternative to administering an inhalant for young children. Instructing the child to prolong his/her inhalation is incorrect, as this is used to reduce side effects of using inhalants. Assessing the child's mucous membranes is incorrect, as this action is used to identify any break in the continuity of the membranes and will not assist with the coordination of inspiration. Providing simple written instructions is incorrect, as this will enhance the teaching/learning process of the child and not the coordination of the child's inspiration.

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients? A) gluteus maximus B) ventrogluteal C) rectus femoris D) upper chest

B) ventrogluteal The ventrogluteal or deltoid muscles may be the preferred intramuscular sites for older adult clients experiencing impaired mobility. This site has the potential of retaining greater muscle mass longer than other sites. It is also usually less painful for the client. The dorsogluteal site, which has the gluteus maximus, should be avoided because of the risk of damage to the sciatic nerve with diminished musculature. The rectus femoris site is most suitable for infants. The upper chest muscle is part of intradermal injections, not intramuscular injections.

Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response? A) "I will log in so that you can proceed with medication delivery B) "I am giving you my password so you can log in C) "I will get the hospital's information system's phone number for you D) "I can log in and give the medications for you

C) "I will get the hospital's information system's phone number for you Passwords and logins should never be shared with anyone else, nor should a nurse use his or her own password or login information to allow another individual to access the automated medication-dispensing system. Nurse B will not log in and give the medications, but rather will provide a solution by offering contact information for information systems to Nurse A so that he or she can work through their login issue.

The nurse is preparing to insert a short intravenous catheter in a 1-year-old child for a one-time administration of fluids due to dehydration. Which needle would the nurse likely select? A) 22-gauge intravenous catheter B) 19-gauge winged infusion set C) 23-gauge winged infusion set D) 18-gauge intravenous catheter

C) 23-gauge winged infusion set Winged infusion or small vein needles may be used for short-term or one-time infusion therapies or may be used with infants and small children. These are short, beveled needles with plastic flaps or wings. A 19-gauge device would be too large for a 1-year-old client.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? A) place a cotton ball in the ear to absorb excess medication B) instill the medication in the opposite ear if prescribed C) ask the client to maintain the position for some time D) briefly postpone the application for the second ear

C) ask the client to maintain the position for some time After instilling the prescribed number of drops in the client's ear, the nurse should ask the client to maintain the position briefly until the solution travels toward the eardrum. When instilling the medication in the client's ear, the nurse first manipulates the client's ear to straighten the auditory canal. Tilting the client's head away, the nurse then administers the prescribed number of drops of medication. The client remains in this position briefly as the solution travels toward the eardrum. The nurse then places a cotton ball loosely in the ear to absorb the excess medication. The nurse then waits for at least 15 minutes before administering the medication in the opposite ear if prescribed. Briefly postponing the application within the second ear avoids displacing the initially instilled medication when repositioning the client.

The nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? A) place a cotton ball in the ear to absorb excess medication B) instill the medication in the opposite ear if prescribed C) ask the client to maintain the position for some time D) briefly postpone the application in the second ear

C) ask the client to maintain the position for some time After instilling the prescribed number of drops in the client's ear, the nurse should ask the client to maintain the position briefly until the solution travels toward the eardrum. When instilling the medication in the client's ear, the nurse first manipulates the client's ear to straighten the auditory canal. Tilting the client's head away, the nurse then administers the prescribed number of drops of medication. The client remains in this position briefly as the solution travels toward the eardrum. The nurse then places a cotton ball loosely in the ear to absorb the excess medication. The nurse then waits for at least 15 minutes before administering the medication in the opposite ear if prescribed. Briefly postponing the application within the second ear avoids displacing the initially instilled medication when repositioning the client.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? A) clean the external ear of drainage with cotton balls moistened with water or normal saline solution B) straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back C) ask the client to remain lying down for at least 5 minutes D) immediately repeat the application in the second ear if prescribed

C) ask the client to remain lying down for at least 5 minutes Tilt the client's head away from the ear into which the medication will be instilled. Compress the container and instill the prescribed number of drops on the side of the ear canal rather than directly onto the tympanic membrane. Press and release the tragus, the projection of skin-covered cartilage at the opening of the external ear, to facilitate moving the medication toward the eardrum. Place a small cotton ball loosely in the ear to absorb excess medication. If a bilateral administration is prescribed, wait at least 5 minutes before instilling medication in the opposite ear. Briefly postponing the application within the second ear avoids displacing the initially instilled medication when repositioning the client.

A young woman has an IV infusing for magnesium sulfate to treat preterm labor. The woman develops a fever. What is the FIRST assessment the nurse should make? A) monitor the IV infusion rate B) assess the vaginal mucosa C) assess the IV site for redness D) assess the client's blood pressure

C) assess the IV site for redness If tenderness, fever without obvious source, or symptoms of local or bloodstream infection are present, remove the dressing and inspect the site directly.

The nurse is preparing to administer two IV medications. What is the appropriate nursing action? A) prepare to administer through two separate tubes B) administer the drugs through the same tubing C) consult a current drug reference book for IV compatibility D) hold one medication for an hour and administer it after the first medication

C) consult a current drug reference book for IV compatibility The nurse should consult a current drug reference book for compatibility before administering two IV medications. Other answers are incorrect.

The nurse is caring for a client with a secondary urinary tract infection with amoxicillin 250 mg PO being prescribed. The nurse recognizes this drug is routinely administered every 8 hours; however, prescription does not state frequency of administration. The health care provider is no longer present. What is the appropriate nursing action? A) ask nurse supervisor to validate frequency as every 8 hours and update the electronic medication record (EMR) B) input prescription into the EMR to reflect the drug is given every 8 hours, after verifying with the pharmacy C) contact health care provider to clarify prescription by reading back to provider, update the EMR while on the phone, then document as phone prescription D) ask another nurse to validate the frequency as every 8 hours, update the EMR flagging the prescription for the health care provider to review and cosign prescription within 24 hours

C) contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription The nurse should always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should another nurse verify the frequency or clarify the prescription. The nurse should remain on the phone with the provider and read back the entire prescription for verification. Documentation should reflect that it is a phone prescription. Usually the phone prescription has to be reviewed and cosigned by the provider within 24 hours.

A client's EHR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? A) recognize that it is not safe to mix two medications in one syringe B) page the health care provider to determine whether the drugs can be mixed C) determine the compatibility of the two drugs by consulting clinical resources D) collaborate with the pharmacy to have one of the times changed

C) determine the compatibility of the two drugs by consulting clinical resources The nurse must determine the compatibility of the two drugs; some drugs can be safely combined in a single syringe. However, this is not determined by paging the health care provider. There is no need to change the times of administration.

The client's EHR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? A) recognize that it is not safe to mix two medications in one syringe B) page the health care provider to determine whether the drugs can be mixed C) determine the compatibility of the two drugs by consulting clinical resources D) collaborate with the pharmacy to have one of the times changed

C) determine the compatibility of the two drugs by consulting clinical resources The nurse must determine the compatibility of the two drugs; some drugs can be safely combined in a single syringe. However, this is not determined by paging the health care provider. There is no need to change the times of administration.

While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the BEST action by the nurse? A) apply a cool, moist compress for 20 minutes B) slow the rate of infusion until client reports relief C) discontinue the IV side and restart IV in a new location D) monitor the site closely for any signs of complications

C) discontinue the IV side and restart IV in a new location The assessment reveals the IV has infiltrated. The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool, moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.

While receiving a medication IV piggyback, the client' reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the BEST action by the nurse? A) apply a cool, moist compress for 20 minutes B) slow the rate of infusion until client reports relief C) discontinue the IV site and restart IV in a new location D) monitor the site closely for any signs of complications

C) discontinue the IV site and restart IV in a new location The assessment reveals the IV has infiltrated. The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool, moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the student identify what process by which the medication is delivered to the target cells and tissues? A) absorption B) synergism C) distribution D) metabolism

C) distribution The process by which the medication is delivered to the target cells and tissues is called distribution. Absorption is the process by which a medication enters the bloodstream. Synergism is a drug interaction that increases the drug effect. The process of chemically changing the drug in the body is called metabolism; it takes place mainly in the liver.

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation? A) pull out and discard the needle B) discard the equipment and start the procedure from the beginning C) engage safety shield on needle guard and discard needle appropriately D) document the incident and inform the primary care provider

C) engage safety shield on needle guard and discard needle appropriately The needle needs to be disposed of properly after engaging the safety guard because the needle cannot be reinserted due to contamination. A new needle can be attached to the syringe and the remainder of the medication administered after cleansing the site again. The incident does warrant notifying the primary care provider.

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection? A) subcutaneous B) intramuscular C) intradermal D) intravenous

C) intradermal The nurse will use the intradermal route, which is injecting the drug between the layers of the skin. The subcutaneous route is reserved for drugs to be injected beneath the skin but above the muscle. The intramuscular route is reserved for drugs to be injected in the muscle. The intravenous route is reserved for drugs to be instilled into veins.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler? A) it is a battery-operated device that spins B) it suspends finely powdered medication C) it is a canister that contains pressurized medication D) it has propellers that get activated during inhalation

C) it is a canister that contains pressurized medication A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used than the turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation.

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider? A) the nurse should use new tubing when attaching additional IV solutions B) as one bag is infusing, the nurse should prepare the next back so it is ready for a change when less than 10 mL of fluid remains in the original container C) it is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the health care provider's order D) generally, the nurse should change the administration sets of simple IV solutions every 24 hours

C) it is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the health care provider's order The nurse's ongoing verification of the IV solution and the infusion rate with the health care provider's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.

A nursing responsibility is managing IV therapy is to monitor to fluid infusions and to replace the fluid containers as needed. What is an accurate guideline for IV management that the nurse should consider? A) the nurse should use new tubing when attaching additional IV solutions B) as one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container C) it is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the health care provider's order D) generally, the nurse should change the administration sets of simple IV solutions every 24 hours

C) it is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the health care provider's order The nurse's ongoing verification of the IV solution and the infusion rate with the health care provider's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.

The nurse has admitted a client for their scheduled outpatient IV chemotherapy, which will be administered via an implanted vascular access device. Which action will the nurse take when caring for a client with this type of IV access device? A) access the port using a needle no larger than 20-gauge B) aspirate after accessing the device to confirm correct placement C) periodically flush the device to ensure the remains patent D) avoid directly accessing the device due to this being outside of the scope of practice

C) periodically flush the device to ensure it remains patent Implanted vascular devices are periodically flushed to ensure patency. These are accessed with a special noncoring needle, not the needles in common use for other purposes. Nurses who have been trained to do so can access such devices within their scope of practice. Aspiration is neither recommended nor safe as a method of confirming placement.

The nurse is assessing a client who has seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation? A) instruct the client to return to taking the current prescribed medication until it is all gone B) offer to speak to the provider for different treatment options C) provide education on taking all antibiotics for effective treatment D) instruct the client to take both the current antibiotic along with a new prescribed antibiotic to avoid antibiotic resistance

C) provide education on taking all antibiotics for effective treatment Although benefits of antibiotics may be felt in a few days after starting therapy, the nurse will teach the client that the entire course of medication must be taken to rid the body of infection. Discontinuing the antibiotic prematurely may cause the infection to reoccur. The incomplete use of an antibiotic is one factor that contributes to the evolution of resistant microbial organisms so the nurse would not instruct the client to returning to the previous regimen. Consulting the health care provider for alternate treatment options may or may not be applicable and also is not particularly the most important. The mixture of antibiotics would typically not be prescribed in this client.

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the PRIORITY nursing action? A) request counseling on the potential for infection B) document the injury C) report the needlestick to the nurse manager D) obtain the client's blood to be tested for HIV and HBV

C) report the needlestick to the nurse manager Upon encountering a needlestick, the nurse's priority action is to report the injury. Other actions can take place after the injury has been reported.

The nurse has begun caring for a surgical client who has been prescribed preoperative antibiotics prior to bowel surgery. While the nurse will adhere to all the principles of safe medication administration, which of the rights of administration will the nurse pay special attention to in this situation? A) dose B) route C) time D) client

C) time The rights of medication administration include right client, right drug, right route, right dose, right time, right reason, and right documentation. While the nurse will adhere to all of these, timing is particularly important for preoperative medications, because these must be times so that peak efficacy aligns with the time of peak risk.

The nurse needs to administer a prescribed injection to a toddler. Which injection site is MOST suitable for the client? A) dorsogluteal site B) ventrogluteal site C) vastus lateralis site D) deltoid site

C) vastus lateralis site The vastus lateralis site is most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles. The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed. The ventrogluteal site, however, is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children.

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube? A) add medications to the formula B) mix all the medications together in 15 mL of water C) use cold water when mixing powdered medications D) avoid crushing sustained-release pellets

D) avoid crushing sustained-release pellets When administering medications through an enteral tube for a tube-fed client, the nurse must avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption. The nurse should not add medications to the formula because some medications may interact with the components in the formula, causing it to curdle or change its consistency. Additionally, a slow infusion would alter the medication's dose and rate of absorption. The nurse should mix each medication separately, not together, with at least 15 to 30 mL of water. The nurse should use warm water when mixing powdered medications to promote dissolving the solid form.

A nurse is administering an intradermal injection to a client for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's BEST action in this situation? A) choose another site and reinject the medication B) prepare another syringe and administer it to the client at the same site C) document the administration as correctly administered D) document the administration and inform the primary care provider

D) document the administration and inform the primary care provider A wheal or blister indicates that the medication has been injected into the dermis. If the wheal or blister does not appear, the medication has most likely been given into the subcutaneous tissue and must be reinjected into another site. The primary care provider needs to be notified that the skin test needs to be administered again so that an order can be obtained.

The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the BEST action by the nurse? A) call the health care provider to request oral antibiotics B) flush the lock with heparin solution C) administer the prescribed antibiotics as prescribed D) insert a new IV medication lock and remove the old one

D) insert a new IV medication lock and remove the old one The nurse is to flush the medication IV lock every 8 to 12 hours, or depending on the facility policy. When flushing the IV lock, the nurse verifies the patency of the lock by aspirating blood return and the lock should flush without resistance. If the nurse is unable to flush without resistance, if there is leaking from the site during flushing, or if patency cannot be verified, the nurse should remove the IV lock and insert a new IV lock. If the nurse has resistance with flushing with saline, flushing with heparin would not be an appropriate option. The nurse should not administer the antibiotic if the IV lock is resistant during flushing. Calling the health care provider to change the order is not appropriate.

Which instruction by the nurse could assist the client in estimating the amount of medication in the canister? A) shake the canister B) press down on the canister once C) insert the canister into the holder D) look on the canister and see how many puffs the canister contains

D) look on the canister and see how many puffs the canister contains The most reliable method is to look on the canister and see how many puffs the canister contains. Divide this number by the number of puffs used daily to ascertain how many days the MDI will last. For instance, if the MDI contains 200 puffs and the client takes 6 puffs per day, the MDI should last for 33 days. Keep a diary or record of inhaler use and discard the inhaler on reaching the labeled number of doses. The canister helps distribute the drugs in the pressurized chamber and is therefore incorrect. Pressing down on the canister once releases the medication and is therefore incorrect. Inserting the canister into the holder is incorrect, as this is the first step in preparing to take the medication.

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be MOST appropriate for the nurse to administer the secondary infusion by gravity? A) placing the secondary and primary infusion at equal height B) placing the primary solution higher than the secondary solution C) stopping the primary solution until the secondary infusion is completed D) placing the secondary infusion higher than the primary solution

D) placing the secondary infusion higher than the primary solution The nurse should place the secondary infusion higher than the primary infusion. This will allow the secondary infusion to infuse first. When completed, the primary infusion will continue to infuse. The other options are not correct.

Which technique should the nurse employ when instilling otic medication in an adult ear? A) tilt the client's head toward the ear in which the medication is being instilled B) tilt the client's head back with face upward C) pull the client's ear down and back D) pull the client's ear up and back

D) pull the client's ear up and back Pulling the client's ear up and back is correct, as this will straighten the auditory canal of the adult client. Tilting the client's head towards the ear in which the medication is being instilled and tilting the client's head back with face upward are incorrect, as these techniques will allow the medication to drain outside the ear. Pulling the ear down and back is incorrect, as this technique is used to straighten the auditory canal of a child, not an adult.

The nurse is caring for a confused client who requires a transdermal patch application. Which location will the nurse choose to apply the patch? A) side of buttock B) upper arm C) lower abdomen D) upper back

D) upper back The nurse will apply the patch to the upper back, as this makes it difficult for the confused client to pick at or remove the patch. The other locations are not appropriate or ideal, as the client could pick at or remove the patch more easily.

The nurse is preparing to withdraw liquid medications from an ampule for injection into an IV. What is the appropriate action for the nurse to take when withdrawing the medication? A) use a needleless IV injector B) withdraw the medication and then squirt some of the medication out before injecting C) choose a smaller needle for injection so no particles will enter the syringe D) use a filter needle to withdraw the medication

D) use a filter needle to withdraw the medication Filter needles should be used whenever withdrawing medication for injection from an ampule, due to the risk of glass particles being aspirated into the syringe. The filter needle contains a membrane that acts as a barrier by blocking the entrance of glass shards. A needleless injector will not protect the client from inadvertent glass shards in the solution. Squirting out some of the solution will not eliminate the potential for glass shards and may cause the client to receive a lower dose of medication than is required. A smaller needle will not filter out the glass particles that may be present.

The nurse is administering a client's scheduled intramuscular injection. What is the nurse's MOST appropriate action?

The nurse should support the ventrogluteal site with the nondominant hand and wear gloves during in an intramuscular injection. Gloves should be worn, and a 90-degree insertion is preferred.