Exam 1 Medication Administration/ Vital Signs End of Chapter Review Questions

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A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. " I will be sure to ask my client what their pain level is on a scale of 0 to 10." 2. "I know that I should follow up after giving medication to make sure it is effective." 3. "I will be sure to cue in to any indicators that the client may be exaggerating pain." 4. "I know that pain in the older client might manifest as sleep disturbances or depression."

"I will be sure to cue in to any indicators that the client may be exaggerating pain."

Which of the following guidlines must a nurse use for taking verbal or telephone orders? (select all that apply) 1. Follow the health care agency guidlines regarding authorized staff who may receive and record verbal or telephone orders. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to heath care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

1, 2, 3, 4, 5

An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What actions should the nurse take to help the older adult? (Select all that apply) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.

1, 2, 5

After receiving an IM injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (select all that apply) 1. Assess the injection site 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment finding. 4. Document assessment finding and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.

1, 3, 4

Which aspects of the patients care related to the administration of heparin can the nurse delegate to the nursing AP? (select all that apply) 1. Notify the nurse if there are any signs of bleeding. 2. Assess the vital signs for possible symptoms of bleeding. 3. Assess bleeding sites and apply appropriate pressure to the sites. 4, Notify the nurse if there is blood noted in the patient's urine. 5. Notify the nurse if there is oozing from any puncture sites.

1, 4, 5

The Health care provider has written the following orders. Which order(s) does the nurse need to clarify before administering the medication? (Select all that apply and give rationale) 1) Timoptic .25% solution 1 drop OD BID 2) Metoprolol 12.5mg QD 3) Insulin Glargine 6 u SC twice a day 4) Enalapril 2.5mg. PO 3 times a day, hold for systolic blood pressure <100

1. because there should be a zero in front of 0.25 or wrong dose might be given. 2. because QD is not used anymore it should be spelled out "Daily". 3. the "u" could be mistaken for a zero, 4, or cc. Needs to been spelled out "unit"

A nurse is administering an MDI with a spacer to a patient with COPD. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouth piece from MDI and spacer device. 4. Place the spacer mouth piece into patient's mouth and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2 to 5 seconds 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly though mouth for 3 to 5 seconds.

2, 3, 6, 1, 4, 5, 8, 7

The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through IV tubing. Place the following steps in the appropriate order. 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to to time administration. 2. Select injection port of IV tubing closes to patient. Whenever possible, injection port should accept a needless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small gauge needle of syringe containing prepared drug through center of injection port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

2, 5, 4, 6, 1, 3

A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate?n (Select all that apply) 1. Verifying tube placement after medications are given. 2. Mixing all medications together to give all at once. 3. Using an enteral tube syringe to administer medicaitons. 4. Flushing tube with 30 to 60 ml of water after the last dose of medication. 5. Checking for gastric residual before giving the medicaitons. 6. Keeping the head of the bed elevated 30 to 60 minutes after the medication are given.

3, 4, 5, 6

Place the steps for administering an intradermal injection in the correct order. 1. Inject medication slowly 2. Note the presence of a bleb 3. Advance needle through the epidermis to 3mm 4. Using non-dominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5 to 15 degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab.

6, 4, 5, 3, 1, 2

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: Temperature 97.2 degrees F orally, Pulse 52 bpm, BP 101/58 mm Hg, RR 11 breaths per minute, and SpO2 93% on 3 liter of O2 via nasal cannula. Which action would the nurse take first? 1. Document the findings 2. Attempt to arouse the client. 3. Contact the PHCP 4. Check the medication administration history on the PCA pump.

Attempt to arouse the client Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the assessment findings, the nurse would suspect opioid overdose. The client comes first before the pump, documentation, contacting the PHCP

A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication?

Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teach? 1. Taking a rectal temperature for a client who has undergone nasal surgery. 2. Taking an oral temperature for a client with a cough and nasal congestion. 3. Taking an axillary temperature for a client who has just consumed hot coffee. 4. Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic.

Taking an oral temperature for a client with a cough and nasal congestion. Rational: nasal congestion often causes mouth breathing and could give an inaccurate reading. Taking an oral temperature when a client has nasal congestion will cause problems breathing while temperature is being taken.


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