health assessment 2 TTLs

7. Which site should the nurse use when injecting LMW heparin? A. A site 5 cm away from the umbilicus B. The upper thigh C. A site as close to the navel as possible D. The upper arm

A. A site 5 cm away from the umbilicus When LMW heparin is administered subcutaneously, a site on the right or left side of the abdomen, at least 5 cm away from umbilicus, should be chosen. Injecting LMW heparin on the side of the abdomen helps decrease pain and bruising at the injection site. Anticoagulants may cause local bleeding and bruising when injected into areas involved in muscular activity, such as arms and legs.

When preparing to administer a tetanus vaccine to a 65-kg adult, the nurse should choose which size needle? A. 1-in, 23-G needle B. 1-in, 20-G needle C. 1½-in, 23-G needle D. 1½-in, 20-G needle

A. 1-in, 23-G needle For adults weighing 60 to 70 kg, a 1-in needle is used, and immunizations for adults should be administered with a 22- to 25-G needle. Needle size for IM injection is determined by medication viscosity, injection site, patient's weight and age, and the amount of adipose tissue through which the injection must go. A 20-G needle may be used for more viscous medications. A 1½-in needle may be used for adults weighing more than 70 kg.

What does a raised, hardened, red zone around an intradermal test site indicate? A. A positive result from skin testing B. An infected injection site C. Inappropriate technique D. A normal reaction to the intradermal injection

A. A positive result from skin testing A raised, reddened, or hard zone around the test site indicates sensitivity to the allergen or a positive TB skin test result. An infected injection site is warm to the touch and painful. A normal reaction to an intradermal injection is a bleb on the skin surface that eventually resolves completely. Inappropriate technique does not result in an induration.

When a bronchodilator is prescribed for a 5-year-old boy, what should the nurse teach him and a family member? A. A spacer device is recommended. B. He is too young for asthma. C. He will be allowed to use the MDI as needed at school. D. He will be less susceptible to systemic effects.

A. A spacer device is recommended. A spacer device is recommended for young children because of the difficulty coordinating MDI activation and inhalation. Asthma can begin at 2 years of age or younger. Many school systems do not permit self-administration with MDIs. Children are more, not less, susceptible to the systemic effects of bronchodilators.

When administering insulin, what should the nurse do to minimize pain during the injection? A. Allow alcohol skin preparation to dry before injecting B. Inject the insulin just after taking it from the refrigerator C. Insert the needle slowly while injecting D. Choose the deltoid site for injection

A. Allow alcohol skin preparation to dry before injecting Pain during insulin injections may be decreased by allowing the alcohol skin preparation to dry before injecting the insulin, injecting room temperature insulin, and inserting the needle quickly. Insulin sites should be rotated within one anatomic area; the anatomic areas include the abdomen, the arms, the thighs, and the buttocks.

The nurse planning to instill ear medication notices that the medication is cold. What is the most appropriate nursing action? A. Allow the ear drops to warm to room temperature. B. Instill the medication as it is. C. Heat the bottle in the microwave. D. Omit the dose.

A. Allow the ear drops to warm to room temperature. Medication may be warmed to room temperature per the organization's practice. Warming the medication prevents nausea and vertigo that may occur if the instilled medication is too cold. Cold medication may cause unnecessary discomfort for the patient. Using the microwave may overheat the medication and inactivate or destroy proteins. Overheated medication places the patient at risk for a burn. Omitting the dose is not an appropriate action.

What should the nurse teach a patient about the use of antianginal medication? A. Apply the medication to the chest area, back, upper arms, or legs. B. Apply medication in a circle no larger than a dime. C. Apply medication to the back of the neck for 15 minutes and then remove. D. A transient headache is an expected adverse effect after application.

A. Apply the medication to the chest area, back, upper arms, or legs. Antianginal medication may be applied to the chest area, back, upper arm, or legs. It should not be applied on hairy surfaces or over scar tissue. The application site should be rotated with each dose to help prevent skin irritation. If the patient complains of a headache, ointment should be applied further from the head. Antianginal medication is designed to be absorbed slowly over several hours; therefore, it should not be removed after 15 minutes. Antianginal medication ointment is ordered in inches and may be measured on small sheets of paper with ½-inch markings. Topical antianginal medication is designed to be absorbed slowly; applying the ointment in a circular motion on the skin enhances absorption of the medication, causing more rapid absorption than intended.

An older patient is being discharged home with an order for twice-daily IM injections. What instruction should the nurse include for this patient? A. Apply topical analgesic to the injection site before administration. B. It is best to administer the injection himself or herself so that the patient knows that he or she is using the correct site. C. Needles can be safely disposed of in a cardboard milk carton. D. It will help absorption to get up and walk immediately after each injection.

A. Apply topical analgesic to the injection site before administration. Adult patients who require frequent injections should be instructed to apply topical analgesic to the injection site before administration. Self-administration of an IM injection is difficult. A family member or friend should be trained to administer the injection. Needles should be disposed of in sharps containers or containers that are in compliance with community guidelines. Cardboard does not provide safety from sharps injuries. Older adults may be at high risk for falls immediately after receiving an injection because of guarding the injection site and loss of muscle tone and strength.

When teaching a patient to administer eye medication, what should the nurse instruct the patient to do? A. Clean from the inner to the outer canthus. B. Do not repeat a dose, even if most of the drops fall on the outer lid margin. C. Remove any crusted, old drainage with a dry cloth. D. Clean from the outer to the inner canthus.

A. Clean from the inner to the outer canthus. The eye should always be wiped clean from the inner to the outer canthus to prevent entrance of microorganisms into the lacrimal duct. Cleaning from the outer to the inner canthus is contraindicated because the risk of introducing bacteria into the lacrimal duct is increased. If crust or drainage is present along the eyelid margins or inner canthus, it should be wiped away gently. Soak any crust that is dried and difficult to remove by applying a damp washcloth or cotton ball over the eye for a few minutes. If most of the drops fall on the outer lid margin and not into the conjunctival sac, the patient will not obtain the therapeutic effects of the drug, and therefore, the dose may need to be repeated.

A patient treated with nebulized medications in the emergency department is being discharged with a prescription for nebulized medications. Which discharge instructions should the nurse include for this patient? A. Clean the nebulizer according to the manufacturer's instructions. B. Wash the nebulizer tubing once each day with a mild detergent and then rinse it thoroughly. C. Do not let the nebulizer parts dry out. Keep them moist to facilitate better functioning. D. The nebulizer itself should be cleaned weekly by soaking it in a 1:1 solution of water and bleach.

A. Clean the nebulizer according to the manufacturer's instructions. Cleaning the nebulizer equipment properly helps prevent bacterial growth. The nebulizer should be cleaned according to the manufacturer's instructions. The tubing should not be washed. Tap water should not be used to rinse the nebulizer; tap water may contain microorganisms. Allowing the parts to dry completely discourages bacterial growth.

When removing the urinary catheter, the nurse meets resistance. What immediate action should the nurse take? A. Stop pulling the catheter and check the balloon to determine if it has been completely deflated. B. Ask the patient to push as if voiding and then pull gently on the catheter. C. Notify the practitioner. D. Reinflate the balloon and then deflate it again.

A. Stop pulling the catheter and check the balloon to determine if it has been completely deflated. If resistance is met, the nurse should stop pulling the catheter and aspirate the balloon again to make sure all fluid is removed. If resistance is still encountered after checking the balloon, the nurse should stop the procedure and notify the practitioner. Pulling the catheter when the balloon is not deflated completely or reinflating the catheter when it is partially removed can cause urethral trauma.

While preparing to insert a suprapubic catheter, the practitioner notes that the patient has a history of peritonitis with laparoscopy. What should the practitioner do? A. Consider placement with ultrasound. B. Continue with blind catheter placement. C. Ask the patient to empty the bladder. D. Inquire if the laparoscopic examination determined the cause of the peritonitis.

A. Consider placement with ultrasound. Blind placement of a suprapubic catheter is not recommended if the patient has had lower abdominal surgery, pelvic irradiation, or intraperitoneal surgery. Placement in these patients should be done with the assistance of ultrasound. Contraindications for suprapubic bladder catheterization include a nonpalpable bladder or a bladder not seen on ultrasound. The cause of the peritonitis, although informative for medical history collection, would not have any direct impact on the insertion of a suprapubic catheter.

The nurse is teaching a patient with a sinus infection about long-term use of the decongestant nasal sprays. How may the decongestant actually worsen nasal congestion? A. Creating a rebound effect B. Causing nasal bleeding C. Disintegrating nasal cartilage D. Bursting nasal capillaries

A. Creating a rebound effect Long-term use of a decongestant nasal spray may actually worsen nasal congestion by creating a rebound effect that increases congestion. Decongestants do not typically cause nasal bleeding or disintegrate nasal cartilage. Decongestants do not typically burst nasal capillaries; however, pressure caused by frequent nose blowing and nose wiping may cause nasal capillaries to burst.

While preparing to mix medications from two different vials, the nurse inadvertently withdraws slightly too much medication from the second vial. What should the nurse do next? A. Discard the syringe and start over B. Remove any excess air from the syringe and administer the medication C. Remove the needle and syringe from the vial and expel the slight overage before administering the medication D. Expel an amount of fluid equal to the second medication (including the slight overage) in the sink and redraw up the second medication

A. Discard the syringe and start over If the nurse draws too much medication into a syringe containing another medication, he or she must discard the syringe and start over. If the nurse expels the air or a portion of the medication and then gives the medication, he or she would be making a medication error because it is impossible to expel only one type of insulin once mixed in a syringe. The dose of either medication cannot be accurately determined either before or after expelling any amount of either medication because the two medications have already begun to mix.

After insertion of a suprapubic catheter, a trace amount of blood is noted in the urine. What should the first action be? A. Documenting the amount, color, and consistency of blood in the urine B. Starting the patient on antibiotics C. Irrigating the bladder to remove the clots D. Encouraging the patient to drink more fluids

A. Documenting the amount, color, and consistency of blood in the urine A trace amount of red blood cells in the urine is normal after the procedure. Documenting the initial amount, color, and consistency of blood in the urine will give the practitioner a baseline for comparison if changes occur later. A large number of clots indicates abnormal bleeding. Antibiotics are not necessary unless findings from a urinalysis are suggestive of an infection. The patient has already been instructed to drink 2000 ml or approximately eight 8-ounce glasses of fluid a day to keep the catheter from becoming occluded, and a trace amount of red blood cells is expected at this time; therefore, telling the patient to drink more fluids is not indicated at this time.

What should the nurse do if the patient reports temporary blurred vision after receiving a mydriatic eye drop? A. Explain to the patient that temporary vision blurring is not unusual. B. Flush the patient's eyes with normal saline for 30 minutes. C. Discontinue the medication and notify the practitioner immediately. D. Explain to the patient that the eye drop concentration is probably too strong.

A. Explain to the patient that temporary vision blurring is not unusual. Certain eye drops, such as mydriatics and cycloplegics, temporarily blur a patient's vision. The wrong drug concentration may lead to an overdose of medication for the patient that may prolong the blurring, but the effect will be temporary. It is not necessary to flush the eyes or notify the practitioner because temporary vision blurring is expected. Flushing the eye washes away any medication that has been administered. The nurse should not discontinue a medication without a practitioner's order.

What should the nurse do first after opening the sterile glove package? A. Identify the right and left gloves before donning. B. Don the left glove before the right glove. C. Don the right glove before the left glove. D. Ask for assistance in donning both gloves.

A. Identify the right and left gloves before donning. After opening the package, the nurse should first identify the right and left gloves. The nurse dons the glove of the dominant hand first, either right or left. The nurse does not require assistance with donning the gloves.

What is the primary reason liquid medications are administered to children? A. Liquid medications are easier to swallow and safer for children. B. Children do not want to chew medications. C. All medications are available in liquid form. D. Because children refuse bitter or distasteful oral preparations, a liquid mixture with honey is recommended for pediatric medications.

A. Liquid medications are easier to swallow and safer for children. Compared with small pills, liquid medications reduce the risk of aspiration. A child would chew a medication if it was crushed and mixed with a small amount (about 1 teaspoon) of a sweet-tasting substance, such as jam, applesauce, sherbet, ice cream, or fruit puree. Not all medications come in liquid form, but liquid forms of medications should be provided to children whenever possible. Honey should not be used with infant medications because of the risk of botulism.

Which technique is appropriate for adding sterile items to a sterile field? A. Open the sterile item while holding the outside wrapper in the nondominant hand. B. Remove the inside wrapper with the nondominant hand. C. Open the sterile item while holding the outside wrapper in the dominant hand. D. Remove the inside packet from the outside wrapper and place the inside packet carefully on the sterile field.

A. Open the sterile item while holding the outside wrapper in the nondominant hand. The nurse should open the sterile item while holding the outside wrapper in the nondominant hand, freeing the dominant hand for use in unwrapping the outer wrapper. The dominant hand has greater dexterity for opening the packaging. The nondominant hand is not sterile, so it should not touch the inside of the sterile wrapper or the contents. The contents should be dropped on the sterile field without being touched.

A nurse is trying to administer eye drops to a 9-month-old infant, but the infant continues to clench the eyes tightly. What should the nurse do next? A. Place the drops at the nasal corner of the eye, with the infant's head gently restrained. B. Require a family member to administer the eye drops while forcing the infant's eye open. C. Place pressure on the eyeball, forcing the infant to open the eye. D. Force open the eyelid, with the infant's head gently restrained, and insert the eye drops.

A. Place the drops at the nasal corner of the eye, with the infant's head gently restrained. To administer eye drops to an uncooperative infant, the nurse should place the eye drops at the nasal corner where the lids meet, with the infant's head gently restrained. When the infant opens the eye, the medication flows into the eye. If the infant is uncooperative for the nurse, a family member may also experience difficulty. Never press directly against the patient's eyeball or force the eyelid open because this may cause damage.

What should the nurse do when reconstituting medications that are packaged in dry powdered form? A. Precisely measure the amount of diluent to be used. B. Shake the vial to disperse the particles. C. Reconstitute all such medications at the beginning of the shift. D. Change needles after injecting the diluent into the vial.

A. Precisely measure the amount of diluent to be used. The vial label specifies the amount of diluent to be used to dissolve the powdered drug and prepare the desired drug concentration. The nurse must measure precisely the amount of diluent to be used. The vial should be rolled gently to disperse the particles, not shaken, to prevent formation of air bubbles. The medication should be mixed just before use. It is not necessary to change needles after injecting the diluent; however, the needle should be verified to be the appropriate gauge and length before the medication is administered to the patient.

Which statement on determining the amount of topical agent required for application is correct? A. Proper dosing is as important with topical medications as with oral medications. B. A thick layer of the topical agent is usually required with an occlusive dressing to cover the area. C. Adverse systemic reactions are minimal if extra medication is applied. D. The amount to apply should be less than the amount previously applied because the previous dose remains on the site.

A. Proper dosing is as important with topical medications as with oral medications. Proper dosing is as important with topical medications as with oral medications. Topical medications are absorbed systemically, and the proper dose ordered by the practitioner must be applied. Getting an occlusive dressing to stick is difficult when a thick layer of medication has been applied, and for most topical medications, it is not required. The nurse should not underestimate a medication's effect because it is administered topically. An excessive amount of topical agent may cause chemical irritation of the skin, contribute to adverse systemic reactions, and provide little therapeutic benefit. A thin, even layer of medication is usually adequate. Previous doses of medication should be removed, and the skin should be cleaned before administering another dose.

When administering an IM injection using the Z-track method, which action is appropriate? A. Pull the skin tissue laterally with the nondominant hand. B. Release the skin immediately after the needle is inserted. C. Refrain from aspirating back on the syringe before injecting. D. Continue to hold back the skin for 30 seconds after removing the needle.

A. Pull the skin tissue laterally with the nondominant hand. With IM injections using the Z-track method, the nurse pulls the overlying skin and subcutaneous tissue laterally with the nondominant hand. The Z-track method reduces pain and medication leakage into subcutaneous tissue. The skin is held in position until the injection has been administered. After withdrawing the needle, the nurse releases the skin, leaving a zigzag path that seals the needle track. IM injections are always aspirated after insertion of the needle and before administering the medication. The exception is for vaccine administration in the vastus lateralis or deltoid muscle because there are no large blood vessels in these sites. The needle is removed smoothly, quickly, and steadily followed by a release of the skin. It is important to release the skin to seal the medication in the muscle.

After administering medication intramuscularly, what should the nurse do? A. Return to the room to evaluate the patient's discomfort and assess the injection site. B. Massage the site to hasten absorption and minimize the soreness. C. Recap the needle to prevent injury and discard it in an appropriate container. D. Pull back on the Z track to ensure that it is still functional.

A. Return to the room to evaluate the patient's discomfort and assess the injection site. The nurse should return to the patient's room within an appropriate time determined by the organization's practice and assess the patient for acute pain, burning, numbness, or tingling at the injection site. Continued discomfort may indicate injury to underlying bones or nerves. Recapping needles increases the risk of a needlestick injury. The uncapped needle (or needle enclosed in a safety shield) and attached syringe should be discarded into a puncture-proof and leakproof receptacle to prevent injury to the patient and health care personnel. After injection, the nurse should apply gentle pressure without massaging the site. Massage may damage underlying tissue. The Z track does not need to be reassessed for functionality.

The nurse is preparing to give the patient an IM injection into the ventrogluteal muscle. The nurse should assist the patient into which position? A. Side-lying position B. Prone position C. Sitting position D. Standing position

A. Side-lying position For injection into the ventrogluteal muscle, the patient lies on the side or back and flexes the knee and hip on the side to be injected. For the vastus lateralis muscle, the patient should lie flat, supine, with the knee slightly flexed. Lying supine allows for optimal visualization of the greater trochanter and knee, which are used as landmarks for the vastus lateralis muscle. For injection into the deltoid muscle, the patient may sit or lie flat with the hand on the hip or the lower arm flexed but relaxed across the abdomen or lap. The nurse should assist the patient to a comfortable position, depending on the site chosen. The patient never stands for an IM injection.

What important point should the nurse emphasize when teaching the patient and family how to use nasal decongestants? A. The dropper should not be shared by family members even if it is cleansed after use. B. Medication should be stored safely between illnesses. C. Nasal sprays may be used as often as needed for nasal congestion. D. The medication is applied topically and does not enter the circulation.

A. The dropper should not be shared by family members even if it is cleansed after use. Nasal sprays or drops should not be shared by family members even if the dropper is cleaned and should be used for only one illness because the droppers of stored medication easily become contaminated. Additionally, medication may become outdated or ineffective while sitting. Overuse of nasal spray decongestants can cause a rebound effect (worsening of mucosal swelling) that may increase the frequency and severity of symptoms and lead to medication dependence. Risk increases as more medication is used. Nasal decongestants can enter the systemic circulation by way of the nasal mucosa or GI tract.

Which consideration is important for a patient taking oral medications? A. The patient's ability to swallow B. The patient's admission weight in kilograms as stated by the patient C. Administering powdered medications 1 hour after mixing them at the bedside D. The use of an injectable medication syringe to administer oral medication

A. The patient's ability to swallow The physical ability to swallow is necessary for the consumption of oral medications. The patient's admission weight in kilograms provides accuracy for weight-based doses. Actual weight should be verified or measured. Stated, estimated, or historic weight should not be used. Powdered medications mixed at the bedside and given immediately reduce the risk to the patient. Waiting to administer a prepared powdered medication increases the risk that the medication may thicken or even harden, making swallowing difficult. Oral medication syringes are preferred. Using a parenteral or injectable syringe for the administration of an oral medication may cause serious consequences.

When removing medication from an ampule, the nurse should take which action? A. Tip the ampule to bring all the fluid within reach of the needle. B. Break the neck of the ampule toward the hands. C. Add a volume of air to the ampule to push the medication out into the syringe. D. Keep the needle against the rim of the ampule.

A. Tip the ampule to bring all the fluid within reach of the needle. The nurse should keep the needle tip under the surface of the fluid and tip the ampule so the fluid is within reach to prevent aspiration of air. The ampule should be broken away from the hands to avoid injury to the nurse. Air should not be added to the ampule; increasing air pressure may force fluid out of the ampule. Solution can drip out of the ampule if the needle touches the rim.

A patient states that he has difficulty breathing when he is exposed to latex. Which type of latex allergy does the patient have? A. Type I allergic reaction B. Irritant dermatitis C. Type IV hypersensitivity D. Type I hypersensitivity

A. Type I allergic reaction Type I allergic reactions to latex can be life threatening. The symptoms include hives, generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea, nausea, hypotension, tachycardia, and respiratory or cardiac arrest. Type IV hypersensitivity symptoms include redness, itching, and hives at the affected site. Type I hypersensitivity is not commonly seen in latex allergies. Irritant dermatitis is a nonallergic response characterized by skin redness and itching.

Which injection site should the nurse choose when administering heparin subcutaneously to a patient with cachexia and minimal peripheral subcutaneous tissue? A. Upper abdomen B. Deltoid C. Upper thigh D. Upper arm

A. Upper abdomen The upper abdomen is the best injection site for a patient with cachexia and little peripheral subcutaneous tissue. The abdomen usually contains a larger amount of subcutaneous tissue than the peripheral areas of the body. Anticoagulants may cause local bleeding and bruising when injected into areas involved in muscular activity, such as arms and legs.

In what injection site should the nurse administer a subcutaneous injection to a 2-year-old child? A. Upper outer aspect of the triceps B. Upper half of the anterior thigh C. Outer fatty area of the thigh D. Upper half of the abdomen

A. Upper outer aspect of the triceps The preferred site for giving a subcutaneous injection to a child between 12 and 36 months old is the upper outer aspect or the triceps. For an infant up to 12 months old, the outer fatty area of the thigh should be used. The anterior thigh is used for intramuscular injections on infants and young children. The abdomen is used for subcutaneous injections of heparin and sometimes insulin for in adults.

The nurse is preparing to administer a nebulized medication. If possible, the nurse should assist the patient to which preferred position before administration? A. Upright position B. Supine position C. Side-lying position D. Semi-Fowler's position

A. Upright position The optimal position for administering a nebulized treatment is the upright position to facilitate full inhalation effort. The nurse should assist the patient to this position if at all possible. The supine, side-lying, and semi-Fowler's positions may not facilitate optimal medication administration.

The nurse is caring for an older adult patient with an indwelling catheter who is becoming agitated and confused and has an elevated temperature. The patient does not have dysuria, urgency, frequency, or odor. What should the nurse consider as the possible cause? A. Urinary tract infection B. Stroke C. Dehydration D. Gastroenteritis

A. Urinary tract infection This older adult patient may be exhibiting atypical signs and symptoms of a urinary tract infection (e.g., fever; mental status changes, including agitation, lethargy, confusion). Symptoms of a stroke include weakness or paralysis of one side of the body, partial or complete loss of voluntary movement, and numbness or tingling. Symptoms of dehydration include decreased urinary output, dry mouth, thirst, decreased capillary refill, and poor skin turgor. Symptoms of gastroenteritis include diarrhea and vomiting.

The nurse prepares to mix two medications in one syringe. One medication is from a multidose vial and the other is from an ampule. What should the nurse do first in the correct sequence of preparation? A. Withdraw the medication from the vial B. Prepare the medication from the ampule C. Draw all of the medication out of both the ampule and the vial D. Insert air into the ampule

A. Withdraw the medication from the vial The medication from the vial is withdrawn first to prevent any contamination of the vial with medication from the ampule. Withdrawing from the ampule first can contaminate the multidose vial. The nurse should withdraw only the required dose from the multidose vial. Inserting air into an ampule is not necessary because it is not a vacuum system.

Why must the drops and solutions instilled into the ear be sterile? A. To prevent loss of hearing B. Because a patient has an inflamed ear canal C. In case the eardrum is ruptured D. Because the ear is sterile

C. In case the eardrum is ruptured Although structures of the outer ear are not sterile, sterile drops and solutions must be used in case the eardrum is ruptured. Nonsterile solutions introduced into the middle ear may cause serious infection. Sterile solutions should always be used, even if there is no ear canal inflammation. Temporary hearing loss occurs until the medication is absorbed and is not related to the sterility of the medication.

The nurse is teaching a student nurse about indwelling urinary drainage catheters. The nurse asks the student nurse what is the purpose of reducing the use and duration of an indwelling catheter. Which response indicates the student nurse understood the teaching? A. "Catheter removal promotes bladder tone." B. "There is a high risk of CAUTIs." C. "Catheter removal stimulates normal filling and emptying of the bladder." D. "Removal of the catheter increases length of stay."

B. "There is a high risk of CAUTIs." Indwelling catheters should be removed as soon as possible after insertion because of the risk for a CAUTI; the longer a catheter is in place, the higher the incidence of infection. Evidence does not support the practice of intermittently clamping and releasing the catheter to promote bladder tone and stimulate normal filling and emptying of the bladder. Removal of an indwelling catheter as soon as possible decreases the risk of infection and would result in a shorter length of stay.

When treating an 80-kg adult, the nurse should inject the IM medication at which angle? A. 60 degrees B. 90 degrees C. 15 degrees D. 45 degrees

B. 90 degrees The nurse should administer an IM injection so that the needle is perpendicular to the patient's body or as close to a 90-degree angle as possible; 15-, 45-, and 60-degree angles are not perpendicular enough to administer the IM injection correctly.

When drawing up medication from a new single-dose vial, the nurse should first remove the plastic cap and then do what? A. Immediately withdraw the medication needed. B. Apply friction while swabbing the rubber seal with alcohol. C. Remove the rubber seal to access the medication. D. Place the cap aside and recap the vial later.

B. Apply friction while swabbing the rubber seal with alcohol. Not all drug manufacturers guarantee that rubber seals of unused vials are sterile; therefore, the nurse should apply friction while swabbing the rubber seal with alcohol and allow the rubber seal to dry before preparing and withdrawing medication. The rubber seal is not removed; the nurse accesses the vial by inserting a needle through the rubber seal. Vials come packaged with a cap that cannot be replaced after seal removal.

How should the nurse give a subcutaneous injection to a patient who is obese? A. At a 45-degree angle within the tissue fold B. At a 90-degree angle below the tissue fold C. With a ½-inch (1.3-cm) needle D. In the ventrogluteal area at a 20-degree angle

B. At a 90-degree angle below the tissue fold Body weight and amount of adipose tissue influence the choice of needle length and angle of insertion. For patients who are obese, the nurse can pinch the tissue and insert a longer needle through the fatty tissue to reach the base of the skin fold; the correct angle of injection is 90 degrees. A 25-G ⅝-inch needle inserted at a 45-degree angle is appropriate for a patient of normal size. A subcutaneous injection is not given in the ventrogluteal areas at a 20-degree angle.

A patient with an infected left frontal sinus will be continuing medication instillation at home and is performing a return demonstration to the nurse. Which action indicates the need for additional patient education from the nurse? A. Holds the dropper just inside the nostril B. Blows nose gently immediately after instilling the medications C. Washes hands before and after instillation D. Remains supine for a few minutes

B. Blows nose gently immediately after instilling the medications Although gently blowing the nose before instilling nasal medication is acceptable in most cases, patients should avoid blowing the nose immediately afterward to prevent expelling the medication. The dropper should be positioned just inside the nostril. The patient should remain supine for a few minutes. Hand hygiene should be performed before and after instillation.

During the sterile field setup, the nurse accidently spills saline over entire field. What should be the nurse's next step? A. Complete the procedure quickly because the saline is sterile. B. Consider the sterile field contaminated. C. Check for spillage on the floor. D. Place a sterile drape over the field and continue the procedure.

B. Consider the sterile field contaminated. When liquids permeate the sterile field or barrier (called strike-through), the sterile field is considered contaminated. Completing the procedure would not be best practice because the spill has contaminated the sterile field. Spilling liquids on the floor is a concern but not the first priority related to the sterile field. Placing an additional sterile drape over a wet surface poses a risk of saturation and contamination of the drape and anything that touches it.

A patient has been receiving pain medication intramuscularly every 4 hours for several days. The nurse is preparing to administer another IM injection for pain control 4 hours after the patient's last injection. What action should the nurse take before administering the pain medication? A. Tell the patient to try to hold off an extra hour to begin weaning. B. Determine which sites have been used most recently. C. Begin administering placebos with each alternate administration. D. Inform the practitioner that the patient is seeking drugs.

B. Determine which sites have been used most recently. Injection sites should be rotated to decrease the risk of hypertrophy; the nurse should determine recently used sites and select a different site. Although the practitioner should be made aware of how much medication the patient is receiving, the nurse is not in a position at this point to classify the patient as drug seeking. By the same token, the patient is reporting pain and should not have to wait for pain relief. The use of placebos is highly controversial and not endorsed by several professional organizations.

As the nurse is about to give a medication, the patient says, "This pill that you are giving me for my heart looks different than the one I was taking at home." What should the nurse do next? A. Administer the medication. B. Explore the patient's concerns, notify the practitioner, and verify the practitioner's order. C. Document that the medication was withheld. D. Notify the practitioner.

B. Explore the patient's concerns, notify the practitioner, and verify the practitioner's order. It is important for the nurse to allow the patient to verbalize concerns about the medication, and the nurse must also notify the practitioner and verify the practitioner's order. Administering the medication without taking the correct actions may result in a medication error. The medication should not be withheld once the order has been verified, so this would not be documented.

Which of the following actions should the nurse take when instilling ear drops or solution into an adult's ear? A. Have the treated ear facing down B. Gently pull the pinna upward and outward C. Gently pull the pinna downward and backward D. Leave the ear in a neutral position

B. Gently pull the pinna upward and outward When administering ear medication for adults and children more than 3 years old, the nurse should have the treated ear facing up and gently pull the pinna upward and outward to straighten the ear canal. If the treated ear faces down, the medication will leak out and not be absorbed. The nurse should have the ear facing up and pull the pinna downward and backward for a child 3 years old or younger. Leaving the ear in a neutral position inhibits access to deeper external ear structures, whereas straightening the ear canal provides direct access.

How should the nurse remove the first sterile glove? A. Grasp the inside of the cuff with the gloved hand and remove. B. Grasp the outside of the cuff with the other gloved hand and remove. C. Grasp the outside of the cuff with the ungloved hand and remove. D. Grasp the fingers of the glove with the other gloved hand and remove.

B. Grasp the outside of the cuff with the other gloved hand and remove To prevent the spread of the glove's contaminated contents, the nurse should remove the first glove by grasping the outside of the cuff with the other gloved hand so the glove can be turned inside out when pulled off. Grasping the outside of a glove can contaminate an ungloved hand. Grasping the inside of the cuff with a gloved hand can contaminate the underlying skin of the wrist and hand. Removing gloves by grasping the fingers of the glove does not permit the nurse to turn the glove inside out to contain the contaminated contents of the glove and may allow contaminants on the glove to splatter or rub off on the nurse's skin.

Which action should the nurse take when instilling ear drops? A. Insert the dropper far enough into the ear to occlude the ear canal. B. Hold the dropper above the ear canal. C. Use gentle force, if needed, to ensure that the entire dose has been delivered. D. Use a cotton-tipped applicator to hold the solution in the ear.

B. Hold the dropper above the ear canal. The nurse should instill prescribed drops while holding the dropper above the ear canal to prevent ear canal trauma from the dropper and allow for visualization of ear drop administration. Occluding the ear canal with the dropper during instillation may cause pressure in the canal and subsequent injury to the eardrum. The nurse should not use any force to instill ear drops. Forcefully instilling drops into an occluded canal can cause injury to the eardrum. Cotton-tipped applicators should not be used to keep medication in the ear canal.

Which patient instructions are correct when administering a buccal medication? A. Chew the medication before swallowing. B. Hold the medication against the cheek and gum membranes. C. Swallow the medication after 30 seconds. D. Hold the medication under the tongue.

B. Hold the medication against the cheek and gum membranes. A buccal medication must be dissolved against the cheek and gum membranes. The sublingual route is used to administer medication under the tongue. Medication is dissolved, not swallowed or chewed, when using the buccal route.

What should the nurse teach the patient about administering aerosolized spray medication? A. Hold the spray about 2 to 3 inches from the skin to ensure that the skin is adequately covered. B. Hold the spray at an appropriate distance per the manufacturer's instructions and practitioner's orders to ensure that the correct amount of medication hits the skin surface. C. Do not to shake the container before application because foaming may result. D. Spray for approximately 45 seconds to ensure adequate distribution.

B. Hold the spray at an appropriate distance per the manufacturer's instructions and practitioner's orders to ensure that the correct amount of medication hits the skin surface. The usual recommended distance for holding the spray container ensures that the appropriate amount of medication per manufacturer's instructions and practitioner's orders hits the skin surface. Holding the container too close results in a thin, watery distribution. The container should always be shaken before application to ensure proper dispersing. The medication should be sprayed long enough to cover the area per the manufacturer's recommendations.

A family member is administering a nebulizer treatment to a 5-year-old child. The nurse plans additional teaching when observing which action by the family member? A. Holding the mouthpiece between the child's lips with gentle pressure B. Holding the nebulizer away from the child's mouth and nose C. Using the face mask when the child is too tired to hold the nebulizer D. Having the child hold the mouthpiece between his own lips

B. Holding the nebulizer away from the child's mouth and nose Holding the mouthpiece away from the mouth leads to ineffective medication delivery. Using a face mask when a child is too tired or is unable to hold the mouthpiece correctly is acceptable. The mouthpiece should be held between the lips throughout the treatment. Having the child hold his own mouthpiece or having a family member hold it for the child is acceptable.

What should the nurse do when administering nasal drops to an infant? A. Have the family member restrain the child for a few minutes after instillation. B. Instill the drops 15 to 20 minutes before feeding. C. Suction the nares vigorously before instilling the drops. D. Feed the infant and then instill the medication.

B. Instill the drops 15 to 20 minutes before feeding. nfants are nose breathers, and the possible congestion caused by nasal medications may inhibit sucking. Nose drops, if ordered, should be administered 15 to 20 minutes before feedings to allow absorption of the medication and to decrease nasal congestion that might make it difficult for the infant to eat and breathe at the same time. Vigorous suctioning should be avoided because it may traumatize delicate tissue. The nurse or parent should attempt to keep the child in the position used for instillation for a brief time after instillation of drops to ensure that the drops come into contact with the affected tissue.

Which statement regarding a sterile procedure is correct? A. Keep the hands below the level of the sterile field. B. Keep the hands above the level of the sterile field. C. Never let the hands touch each other. D. Rest the hands on the undraped portion of the patient's body.

B. Keep the hands above the level of the sterile field. The hands should be kept above the level of the sterile field to avoid contamination. The area below the level of the field is not considered sterile. Two sterile gloved hands may touch each other, but the hands should never touch an undraped part of the patient.

After drawing up the appropriate insulin dose as ordered according to the patient's regular insulin subcutaneous sliding scale, what should the nurse do next? A. Maintain a bubble in the syringe to prevent leakage on administration B. Keep the needle or needleless device on the syringe capped C. Administer the insulin intramuscularly D. Gently roll the syringe to evenly distribute the medication

B. Keep the needle or needleless device on the syringe capped Keeping the needle or needleless device capped maintains sterility of the medication administration. Air bubbles in the syringe barrel cause an inexact amount of medication to be administered. The insulin was ordered to be administered subcutaneously per the sliding scale. The syringe should not be rolled; no mixing is needed for the insulin.

What should the nurse do if urinary retention is suspected after catheter removal? A. Reinsert the catheter. B. Perform an ultrasound and call the practitioner. C. Provide the patient with fluids to stimulate more urine production. D. Inform the nurse on the next shift so that the patient can be reassessed.

B. Perform an ultrasound and call the practitioner. If urinary retention is suspected after removal of the catheter, an ultrasound of the bladder should be performed to determine if the patient is retaining urine. The practitioner should be called after the ultrasound to determine if further actions are required. The catheter is not reinserted without an order. The intake and output should be measured to determine fluid balance, but providing the patient with increases in fluids may only exacerbate the condition. The patient should be treated promptly, with report given to the oncoming nurse.

Before administering oral medications, the nurse must determine the patient's ability to swallow. What is the most appropriate way to do that? A. Ask the patient or family how well the patient swallows. B. Place the thumb and index finger on the sides of the Adam's apple and feel for an elevation. C. Observe the intake of solid foods. D. Ask the patient to swallow a small amount of water and observe the action.

B. Place the thumb and index finger on the sides of the Adam's apple and feel for an elevation. Feeling the patient's Adam's apple for movement and symmetry is the best bedside technique for the assessment of dysphagia. Observing the intake of solid foods or fluids reveals some information about the patient's ability to swallow but is not the best bedside assessment technique. The patient or family member may be unable to determine if the patient is able to swallow medications safely.

When giving instructions about how to use the no-pinch method to inject subcutaneous insulin into a patient, what should the nurse instruct the family member to do? A. Massage the site after the injection. B. Select a 1/5-inch needle and use a 90-degree angle. C. Rotate injection sites each time from one major site to another. D. Insert the needle at a 45-degree angle using a 5-mm needle.

B. Select a 1/5-inch needle and use a 90-degree angle. A 1/5-inch needle inserted at a 90-degree angle is appropriate for using the no-pinch method. Subcutaneous injections should not be massaged because massaging can damage the underlying tissue. Rotating injections from major site to major site is no longer considered necessary to prevent hypertrophy; patients may choose one anatomic area and systematically rotate sites within that region until all potential sites within the area are used, and either move to another anatomic site (e.g., thigh) or start the rotation over in the same anatomic area. If using the "pinch method," the needle should be inserted at a 90-degree angle.

When teaching the patient how to breathe during a nebulizer treatment, the nurse should provide which instruction? A. Perform "huff" coughs after every fourth or fifth breath, allowing for rapid exhalation. B. Take a slow, deep breath with a brief, end-inspiratory pause and then exhale passively. C. Breathe in and out rapidly in a constant rhythm with no pause, as during a respiratory assessment. D. Breathe normally throughout the entire treatment.

B. Take a slow, deep breath with a brief, end-inspiratory pause and then exhale passively. For the most effective medication delivery, the patient should take a slow, deep breath to a volume slightly greater than normal, allow a brief, end-inspiratory pause, and then exhale passively. Rapid breaths do not allow adequate deposition of medication in the airways. The normal breathing pattern is not as effective for depositing medication in the airways. "Huff" coughing is not indicated for nebulizer treatments.

What should the nurse do when preparing medication from a single-dose vial? A. Pull forcefully on the plunger to overcome resistance from the vial. B. Take care to withdraw only the desired volume of medication. C. Aspirate the entire contents of the vial to obtain the correct dose. D. Avoid adding air into the vial airspace.

B. Take care to withdraw only the desired volume of medication. Manufacturers often include a small amount of extra liquid in a medication vial in case of loss during preparation; therefore, the nurse should be sure to withdraw only the desired amount of medication from the vial. Pulling forcefully on the plunger may result in excess air in the syringe and may cause the plunger to separate from the barrel, with subsequent medication loss. Aspirating the entire contents of the vial may increase the likelihood of particles entering the syringe. Air should be added to the vial airspace to enable medication to be withdrawn.

The nurse is to administer an IM injection into the ventrogluteal muscle. Which anatomic landmarks should the nurse use? A. The acromion process and axilla B. The iliac crest and the anterior superior iliac spine C. The posterior superior iliac spine and the iliac crest D. The greater trochanter and the knee

B. The iliac crest and the anterior superior iliac spine To locate the ventrogluteal muscle, the iliac crest and the anterior superior iliac spine should be used as anatomic landmarks. Do to this, the nurse places the heel of the hand over the greater trochanter of the patient's hip with the wrist almost perpendicular to the femur. The nurse uses the right hand for the left hip or the left hand for the right hip and then points the thumb toward the patient's groin, points the index finger to the anterior superior iliac spine, and extends the middle finger back along the iliac crest toward the buttock. The index finger, middle finger, and iliac crest should form a V-shaped triangle, and the center of the triangle should be used as the injection site. The acromion process is used to help locate the deltoid muscle. The greater trochanter and knee are used to locate the vastus lateralis muscle.

A nurse should withhold the administration of medication through a small-volume nebulizer or inhaler in which case? A. The patient experiences coughing. B. The patient develops arrhythmias. C. The patient is unable to self-administer the medication. D. The patient needs administration at a greater frequency than every 4 hours.

B. The patient develops arrhythmias. Arrhythmias may indicate systemic effects of nebulized medication and require a discontinuation of the treatment. Coughing should be assessed and recorded but does not necessarily require that the treatment be discontinued. An inability to self-administer may require changing the method of administration, but it does not require that the treatment be stopped. The practitioner's order determines the frequency of nebulizer treatments.

A patient has a prescription for a medication administered via an MDI. To determine whether the patient requires a spacer for the inhaler, the nurse should assess which of the following? A. The patient's ability to mix medications B. The patient's coordination C. The medication dose D. The schedule for the medication

B. The patient's coordination Spacers are helpful when the patient has difficulty coordinating the steps involved in self-administering inhaled medications. The use of a spacer does not depend on the dose or schedule of a medication. MDIs come premixed so the patient is not required to mix medications.

A mother notices that her child's rash has been getting worse since topical treatment was started, and she notes inflammation and edema. When talking to the mother about her concern, the nurse should explain what? A. It is normal for the skin lesions to get worse before they get better. B. These signs may indicate subacute inflammation. C. There is no need to be concerned unless the child complains of pruritus. D. The topical medication should be discontinued immediately.

B. These signs may indicate subacute inflammation. The nurse should be concerned if the skin site becomes inflamed and edematous. These signs are indicative of subacute inflammation or eczema that may develop if skin lesions worsen. Pruritus may not always be present with worsening symptoms during treatment. It is not normal for skin sites to worsen with treatment. The nurse should always consult the practitioner before discontinuing treatment.

The nurse is mentoring a new graduate nurse. The nurse ensures that the new nurse dons sterile gloves when performing which procedure? A. Peripheral IV insertion B. Urinary catheterization C. Tracheostomy care D. Nasogastric tube insertion

B. Urinary catheterization Urinary catheter insertion is considered a sterile procedure and requires the use of sterile gloves. Peripheral IV insertion, tracheostomy care, and nasogastric tube insertion are considered clean procedures for which nonsterile gloves are sufficient.

A new order is written for insulin glargine and another long-acting insulin. What should the nurse do in preparation for administration? A. First, draw up the insulin glargine into the syringe and then draw up the other long-acting insulin in a second syringe B. Draw up only the insulin glargine into the syringe because the order for the second long-acting insulin was probably a mistake C. Administer the insulins in two separate injections D. First, draw up the other long-acting insulin and then draw up the insulin glargine into the syringe

C. Administer the insulins in two separate injections Glargine is a long-acting insulin. Long-acting insulins should not be mixed with any other form of long-acting insulin, so two separate injections are required. It would not be appropriate for the nurse to assume that the second insulin is a mistake; any questions about a patient's medication orders should be clarified with the practitioner. Whether the insulin glargine is drawn up first or second is irrelevant because insulin glargine may not be mixed with any other insulin.

The nurse is likely to use an intradermal injection to administer medication for which indication? A. Pain B. Low-dose insulin requirements C. Allergy sensitivity D. Anticoagulant therapy

C. Allergy sensitivity Intradermal injections are typically given for allergy testing or TB screening. Because such medications are potent, they are injected into the dermis, where blood supply is reduced. and drug absorption occurs slowly. Pain medications are typically given intramuscularly, orally, or intravenously. Anticoagulants and insulin injections are typically given subcutaneously.

Which action should the nurse take to reduce the risk of aspiration for patients taking oral medications? A. Have the patient use a straw. B. Administer several pills at once to reduce the number of times the patient needs to swallow. C. Allow the patient to self-administer the medication. D. Give all medications before or after meals.

C. Allow the patient to self-administer the medication. Allowing the patient to self-administer oral medications gives him or her more control. The nurse should avoid straws because they decrease the patient's control over volume intake, increasing the risk of aspiration. The nurse should administer pills one at a time, ensuring that each is properly swallowed before the next one is introduced. Oral medications should be timed to coincide with mealtimes or given when the patient is well rested and awake if possible.

What are the only exceptions to medication labeling? A. Liquid medications that are administered in an oral syringe B. Liquid medications that are administered in a cup C. Any medication that is administered immediately by the person who prepared it D. Any medication that is administered during the nurse's shift

C. Any medication that is administered immediately by the person who prepared it According to The Joint Commission's National Patient Safety Goals, the only exceptions to medication labeling are medications still in the original container that are administered immediately by the person who prepared them.

What is the nurse's next step after needle removal following an injection? A. Cap the needle using the two-handed technique B. Apply an adhesive bandage C. Apply gentle pressure to the site D. Cleanse the site with an antiseptic wipe per the organization's practice

C. Apply gentle pressure to the site Applying gentle pressure to the site aids absorption. The uncapped needle or safety-shield-enclosed needle should be discarded in a sharps container; two hands should never be used to recap a needle, as this increases the risk of needle-stick injury. A bandage, if needed, is applied after applying gentle pressure to the site and checking the site. Cleansing the site should be done before the injection is given.

A student nurse is administering enoxaparin (Lovenox®) to a patient by subcutaneous injection. Which technique should the staff nurse question? A. Assessing the patient's medication regimen B. Asking if the patient knows why enoxaparin is being administered C. Aspirating the medication before injecting D. Selecting the abdomen as the injection site

C. Aspirating the medication before injecting Aspirating the medication before a subcutaneous injection is not necessary and should be questioned. Piercing a blood vessel during injection is rare, and aspiration may cause hematoma formation. The student nurse is correct to assess the patient's medication regimen before heparin therapy for drugs that interact with heparin (e.g., aspirin, nonsteroidal antiinflammatory drugs, cephalosporins, antithyroid agents, probenecid, and thrombolytics). The student nurse should also assess the patient's knowledge regarding the medication to be received. When heparin is administered subcutaneously, abdominal injection sites should be used. Anticoagulants may cause local bleeding and bruising when injected into areas such as arms and legs that are involved in muscular activity.

The nurse should understand that removing a urinary catheter without completely deflating the balloon may cause which complication? A. Nausea and vomiting B. Fever and malaise C. Bleeding and trauma D. Concentrated urine and odor

C. Bleeding and trauma Removing a urinary catheter without completely deflating the balloon can cause urethral trauma and increase the chance of bleeding. Nausea, vomiting, fever, and malaise, as well as concentrated urine and odor, are not conditions caused by the removal of a urinary catheter with a partially deflated balloon.

What is the correct way to assist a patient who is having difficulty swallowing tablets and capsules? A. Administer the tablets one at a time with plenty of liquid. B. Insert a nasogastric tube and instill the medication. C. Crush the medication, if allowed, and administer it with a small amount of food. D. Administer the medication with less fluid.

C. Crush the medication, if allowed, and administer it with a small amount of food Crushing the medication is the best option for a patient having difficulty swallowing. Not every medication can or should be crushed. Providing less fluid with the medication makes it more difficult for the patient to swallow. Not every medication can or should be given by the nasogastric route. Additionally, a nasogastric tube insertion requires an order from the practitioner. It may not be safe for a patient who is having difficulty swallowing to swallow large capsules or tablets, even one at a time.

After insertion of a suprapubic catheter in the ED, the practitioner advises the patient to contact the urologist or return to the ED if which situation occurs? A. The patient is unsuccessful at removing the tube. B. Urine output increases. C. Fever develops. D. The patient requires further education to change the catheter.

C. Fever develops. Fever may indicate infection and requires evaluation. The patient should follow up with the urologist or return to the ED if the catheter becomes obstructed but should not attempt to remove the tube independently. Patients are not instructed in how to change their suprapubic catheter in the ED. Decreased urine output may indicate obstruction or equipment malfunction; increased urine output is an expected outcome.

The nurse applying a topical ointment notices a new rash near the original site of administration. What should the nurse do? A. Apply the medication as ordered and cover with a dressing. B. Administer the medication as ordered but avoid the areas with the rash. C. Notify the practitioner to see if the administration is contraindicated. D. Administer a small, thin application of the medication. Rationale: Unless advised to by the practitioner, the nurse should not administer topical medications to skin when a new rash has developed because the rash may indicate an adverse reaction to the medication. In addition, altered skin integrity may affect drug absorption and action. The amount of medication should not be altered. Topical ointments are usually not covered with a dressing. Ointment should be applied only to the thickness indicated by the manufacturer's instructions.

C. Notify the practitioner to see if the administration is contraindicated. Unless advised to by the practitioner, the nurse should not administer topical medications to skin when a new rash has developed because the rash may indicate an adverse reaction to the medication. In addition, altered skin integrity may affect drug absorption and action. The amount of medication should not be altered. Topical ointments are usually not covered with a dressing. Ointment should be applied only to the thickness indicated by the manufacturer's instructions.

A suprapubic catheter insertion might be indicated for which patient? A. One who is pregnant and in her third trimester B. One who is male and has a brother with prostate cancer that has caused prostatic obstruction C. One who has developed a neurogenic bladder following a motor vehicle crash that caused multiple pelvic fractures D. One who needs catheterization for a short time while recovering from sepsis

C. One who has developed a neurogenic bladder following a motor vehicle crash that caused multiple pelvic fractures A neurogenic bladder, pelvic fracture, and/or urethral injury are appropriate indicators for a suprapubic catheter. Pregnancy is a contraindicator for suprapubic bladder catheterization. Although family medical history is important, a male patient's own history of prostatic obstruction, not his sibling's, would be an indication for suprapubic catheterization. Suprapubic catheterization is not intended for short-term use. It is an alternative to long-term urethral catheterization because it has been shown to decrease the incidence of infection.

A patient tells the nurse that he or she has been performing nebulizer treatments at home and that the treatment usually lasts about 10 minutes. How should the nurse respond to the patient? A. Instruct the patient to add additional diluent to the medication so the procedure lasts 20 minutes. B. Instruct the patient to check the nebulizer for compressor function. C. Reinforce that the patient's procedure is effective. D. Reinforce that medication should be administered in 5 minutes or less.

C. Reinforce that the patient's procedure is effective. The length of treatment is until the medication is gone if the equipment is working properly and correct medication and diluent are used. Instructing the patient to add diluent to make the treatment last longer would not be appropriate. The patient should check the nebulizer or compressor function if treatment time is prolonged.

When an inhaled corticosteroid is prescribed, what should the nurse instruct the patient to do? A. Use the inhaled corticosteroid as needed for wheezing or shortness of breath. B. Administer the inhaled corticosteroid before administering a bronchodilator. C. Rinse the mouth after inhalation. D. Avoid using a spacer device.

C. Rinse the mouth after inhalation. The patient should be taught to rinse the mouth with water after using inhaled corticosteroids to prevent oropharyngeal candidiasis and to reduce the amount of medication absorbed systemically. Spacer devices can be used with inhaled corticosteroids if coordination is a concern. Bronchodilators are administered before corticosteroids to open the airways. Inhaled corticosteroids are maintenance therapy for asthma and do not relieve acute symptoms.

When aspirating the syringe during administration of an IM injection, the nurse notices a small amount of blood return. What should the nurse do next? A. Discontinue the procedure and notify the nurse in charge. B. Pull the needle back slightly and then continue with the injection. C. Stop the procedure and repeat the entire preparation of the medication. D. Change the needle and then re-administer the medication.

C. Stop the procedure and repeat the entire preparation of the medication. If blood appears in the syringe, the nurse should stop the procedure, remove the needle, dispose of the medication and syringe properly, and then repeat the entire preparation procedure. Aspiration is recommended for IM injections with the exception of vaccination injections in the vastus lateralis or deltoid muscle. The vastus lateralis and deltoid muscle are the only two sites recommended for vaccine administration because these sites do not contain large vessels that are within reach of the needle. Although small vessels are in the proximity, the needle will rupture them, preventing IV administration. Blood aspirated into the syringe indicates accidental IV placement of the needle. If the nurse takes the proper steps, there is no need to notify the nurse in charge.

What should the nurse do if air bubbles are aspirated while a medication is being drawn up from an ampule? A. Change needles and continue to aspirate medication. B. Expel the air bubbles into the ampule. C. Tap the side of the syringe with the needle pointing upward. D. Return the medication and air to the ampule and begin again.

C. Tap the side of the syringe with the needle pointing upward. If air bubbles are aspirated, the correct technique to remove the air is to tap the side of the syringe with the needle pointing upward. Bubbles rise to the tip of the syringe and can be gently expelled without loss of medication. Changing the needle would not decrease the number of air bubbles in the syringe. Expelling the air into the ampule may result in medication being forced out. Returning medication and air to the ampule may result in loss of medication.

What instructions should the nurse give the patient who is self-administering atropine eye drops? A. Administer eye drops before going to bed for the night. B. Expect the eye drops to produce excessive tearing for about 1 hour after administration. C. Temporarily avoid driving or performing activities that require acute vision. D. Expect the conjunctivae to remain reddened between doses.

C. Temporarily avoid driving or performing activities that require acute vision. Because atropine eye drops paralyze the ciliary muscles of the eye, the patient should refrain from driving or attempting to perform activities that require acute vision until vision has cleared. Other drops that paralyze the ciliary muscles include scopolamine, scopolamine hydrobromide, atropine sulfate, and cycloplegics. Drops may be administered during daytime hours. Excessively reddened conjunctivae or excessive tearing after eye drops are instilled are unexpected outcomes and may indicate ocular irritation and an adverse effect of the drops.

A patient has an infected left frontal sinus. What is the correct head position for administering nose drops to a patient who is supine? A. Flat on a pillow and turned toward the left B. Tilted back over a pillow and turned toward the right C. Tilted back over a pillow and turned toward the left D. Tilted back over a pillow and kept midline

C. Tilted back over a pillow and turned toward the left When the nurse administers drops to the left frontal sinus, the patient's head should be tilted back and toward the left side (the side to be treated). The head should be tilted back to the right if the right frontal or maxillary sinus is infected. The head flat on a pillow is an improper position for any nasal instillation. Head tilted back and midline is the proper position to instill drops into the ethmoid or sphenoid sinus.

A patient with a tracheostomy has an order for a nebulized corticosteroid to be given every 4 hours. Which action should the nurse take? A. Request that the order be changed to an oral corticosteroid. B. Perform deep suctioning of the tracheostomy before each nebulizer treatment. C. Use an adapter to connect the nebulizer to the tracheostomy tube. D. Hold the nebulizer within 6 inches (15 cm) of the tracheostomy.

C. Use an adapter to connect the nebulizer to the tracheostomy tube. A special adapter is available to use for a patient with a tracheostomy. For effective medication delivery, the nebulizer must be connected to the tracheostomy tube. Aerosolized steroids are effective with tracheostomies; a change to an oral corticosteroid is not necessary. Deep suctioning is not a required or necessary step before a nebulizer treatment when a patient has a tracheostomy.

When administering an IM hepatitis B vaccine to an 18-month-old child, the nurse should inject in which muscle? A. Ventrogluteal B. Dorsogluteal C. Vastus lateralis D. Deltoid

C. Vastus lateralis The vastus lateralis muscle is a safe injection site for adults and children and is the preferred site for administration of biologicals (e.g., immunizations) to infants, toddlers, and children through 2 years. For children aged 3 through 18 years, the Centers for Disease Control and Prevention recommends using the deltoid muscle for vaccines, although the ventrogluteal site may also be used. The dorsogluteal muscle is not appropriate for an IM injection.

1. Before the nurse administers medication, which of these is the most critical assessment? A. Diet history B. Drug tolerance C. Surgical history D. Allergy history

D. Allergy history Rationale: Allergy history is the most critical assessment to do before medication administration because an allergic reaction to the medication could prove fatal. Dietary history, surgical history, and drug tolerance are important areas to assess but do not present immediate life-threatening conditions.

What action should the nurse take with regard to the balloon when removing an indwelling urinary catheter? A. Do not deflate the balloon before removing the catheter. B. Manually aspirate all of the fluid before removing the catheter. C. Manually aspirate half of the fluid before removing the catheter. D. Allow the fluid to return to the syringe by gravity before removing the catheter.

D. Allow the fluid to return to the syringe by gravity before removing the catheter. Many manufacturers recommend that fluid return to the syringe by gravity. Manual aspiration results in the development of creases or ridges in the balloon, leading to increased patient discomfort when the catheter is removed. A balloon that is not completely deflated causes discomfort and trauma to the urethral wall, which can result in bleeding as the catheter is removed.

A patient who has recently emigrated from India returns in 48 hours to have a TB test read. What size area of induration is required for a positive test result? A. At least 15 mm B. 5 mm or less C. Between 5 and 10 mm D. At least 10 mm

D. At least 10 mm For a person who is a recent immigrant, an area of induration 10 mm or greater is considered a positive result. For a patient with no risk factors, the induration is considered positive if it is at least 15 mm. An induration between 5 and 10 mm is a positive result for patients with HIV infection, immunocompromised patients, or patients recently exposed to TB. An induration of less than 5 mm is considered a negative result for all categories.

The nurse assessing a patient's skin before application of an ointment notices that the skin is inflamed. What should the nurse do? A. Use mild soap and water to remove the previously applied ointment. B. Discontinue the ointment and notify the practitioner of a skin reaction. C. Apply the new ointment directly over the previously applied ointment. D. Cleanse the area with warm water to remove the previously applied ointment.

D. Cleanse the area with warm water to remove the previously applied ointment. Rationale: If the skin is inflamed, the nurse should use only a warm-water rinse without soap for cleansing because soap may further irritate the skin. The old ointment should always be removed before the next application to avoid a medication overdose. Ointment should not be discontinued without further evaluation and a practitioner's order. Applying the ointment directly over the previously applied ointment should be avoided to minimize the risk of skin irritation.

Why should the nurse remove the previously applied antianginal transdermal patch and cleanse the area before applying the next dose? A. The patch should be removed after 24 hours to allow for a nitrate-free interval. B. The antianginal transdermal patch becomes ineffective after 2 hours. C. The nurse needs to cleanse the skin before reapplying the next dose in the same area. D. Failure to remove the old patch may result in a medication overdose.

D. Failure to remove the old patch may result in a medication overdose. The nurse should locate and remove the old patch and cleanse the area before applying a new patch to a different location. Rotating the transdermal patch diminishes skin irritation. Failure to remove the old patch may result in a medication overdose if a new patch is applied. Cleansing the area is necessary to remove traces of the previously applied dose and adhesive, which may irritate the skin. The medication is slowly absorbed while the patch is in place and remains effective longer than 2 hours. Antianginal transdermal patches should be removed after 10 to 12 hours to allow a nitrate-free interval and reduce the chance of the patient developing tolerance to the medication.

What technique should the nurse use when pouring a sterile solution into a container on a sterile field? A. Remove the seal and cap from the bottle in a downward motion. B. Pour the solution into the receiving container until the container overflows. C. Be sure to recap the bottle after pouring solution into the container. D. Hold the bottle lip above the inside of the sterile container.

D. Hold the bottle lip above the inside of the sterile container. Rationale: The nurse should hold the solution bottle away from the field and the bottle lip above the inside of the sterile container. The seal and cap from the bottle should be removed in an upward motion. The bottle must not be recapped because the lip is now considered contaminated. If a solution overflows and penetrates the sterile field, the field is considered contaminated.

Which step should the nurse take when pouring liquid medications from multidose bottles? A. Remove the medication bottle cap and place it on the work surface upside up. B. Draw doses of liquid medications greater than 10 ml into an oral medication syringe. C. Hold the bottle with the label facing outward while pouring. D. Hold the medication cup at eye level and fill it to the desired level.

D. Hold the medication cup at eye level and fill it to the desired level. Holding the medication cup at eye level ensures correct dosing; the fluid level should be even with the scale marks at the center of the cup or base of meniscus, not the edges. The bottle cap should be placed upside down on the work surface to avoid possible contamination of the rim. An oral medication syringe should be used for doses of liquid medications that are less than 10 ml. When the nurse pours liquid medications, the label should be against the palm of the hand. This allows more accurate observation of the liquid in the medication bottle.

When opening a sterile glove package, the nurse jeopardizes the sterility of the contents when he or she does what? A. Opens the glove package just before the procedure B. Places inner package on clean, dry, surface C. Moves around the sterile field but does not touch the sterile field D. Holds or moves the gloves below the level of the waist

D. Holds or moves the gloves below the level of the waist The area below the waist is considered unsterile; the sterility of an object is compromised if it is moved or held below waist level. Opening the glove package just before the procedure helps maintain sterility. Placing the inner package on a clean, dry surface and moving around the sterile field without touching it do not interfere with or compromise sterility.

What should the nurse do if a patient receiving eye drops reports significant burning or pain that worsens with each instillation? A. Explain to the patient that this is a normal side effect and not to worry. B. Flush the patient's eyes with normal saline for 30 minutes. C. Discontinue the eye drops immediately and make a note in the patient's record. D. Notify the practitioner of the adverse reaction.

D. Notify the practitioner of the adverse reaction. If the patient reports significant burning or pain or experiences localized side effects (e.g., headache, bloodshot eyes, local eye irritation), the nurse should notify the practitioner for a possible adjustment in medication type and dosage. Local side effects may also occur if the eye drops were instilled onto the cornea or the dropper touched the surface of the eye. Significant patient symptoms or complaints after eye drop administration are not normal and should be reported to the practitioner. Flushing the eyes with normal saline should be avoided to prevent instilling medication directly onto the cornea. The nurse should not discontinue the eye drops without direction from the practitioner.

When preparing a sterile field, the nurse notes that a sterile package has a slight tear in the corner. Which action should the nurse now take? A. Cancel the sterile field preparation until a supervisor can be notified. B. Document the small tear in the patient's record. C. Ensure that the tear is not near the actual piece of equipment. D. Obtain a replacement package.

D. Obtain a replacement package. The nurse should check the integrity of the sterile package for punctures, tears, discoloration, moisture, and other signs of contamination. If the integrity is compromised, a replacement should be obtained. The sterile field may still be prepared without delay as long as a replacement package is available. Packaging that is not intact is not relevant for the patient's record. Even a small tear threatens the sterile integrity of the package contents.

The nurse is preparing the morning dose of insulin for a patient. The order is for a mixture of short-acting insulin and long-acting insulin. What should the nurse do to prepare? A. Withdraw the insulin from the long-acting insulin first B. Withdraw the insulin from either vial first C. Do not mix the insulins because they are incompatible D. Withdraw the insulin from the short-acting insulin first

D. Withdraw the insulin from the short-acting insulin first The nurse should always fill the syringe with the short-acting insulin first to prevent contamination of the short-acting insulin with the long-acting insulin. Withdrawing the insulin from the long-acting insulin first and then the short-acting insulin increases the possibility of contaminating the short-acting insulin. These two insulins are compatible; therefore, they may be mixed. The short-acting insulin must be drawn up before drawing up the long-acting insulin.

What does the nurse look for to confirm the correct administration of the intradermal Mantoux test for tuberculosis screening? A. A small bruise at the injection site B. A small drop of blood at the injection site C. Smooth and dry appearance of the skin at the injection site D. A bleb at the injection site

D. A bleb at the injection site A bleb indicates that the medication has been deposited in the dermis. If a bleb does not appear or if the site bleeds after needle withdrawal, the medication may have entered subcutaneous tissues. Bruising indicates that blood has leaked from small vessels. If the site bleeds or the skin bruises, the skin test results are not valid.

What is the correct way for a nurse to hold the eye dropper when administering eye medication to a patient? A. 3 to 4 cm (1⅛ to 1½ inches) away from the eye and directly above the cornea B. 2 to 3 cm (¾ to 1⅛ inches) above the conjunctival sac in the nondominant hand C. So that it is touching the eye D. Perpendicular to the eye just above the conjunctival sac

D. Perpendicular to the eye just above the conjunctival sac The nurse should rest his or her dominant hand on the patient's forehead and hold the medication eye dropper perpendicular to the eye being treated, just above the conjunctival sac. Holding the dropper or administration tip as close as possible to the eyelid without touching the eye or any other surface prevents contamination of the dropper or eye solution. Holding the dropper too far away from the eye makes it difficult to administer the medication without the patient blinking and without contaminating the dropper. Holding the dropper in the nondominant hand is risky because most people are less dexterous with the nondominant hand, which can lead to eye injury and infection possibility. Touching the eye is contraindicated because of the possibility of injury to the eye and the risk of infection.

After the nurse instills medication into the patient's ear, what should the patient do? A. Block the ear with his or her finger and apply moderate pressure B. Turn his or her head to the other side immediately for more medication C. Use a cotton-tipped applicator to keep the medication in the ear D. Remain in a side-lying position

D. Remain in a side-lying position Rationale: After the nurse administers ear drops or solution, the patient should remain in a side-lying position to allow the medication to be completely absorbed. Immediately turning the head may cause the instilled medication to drain out. Cotton-tipped applicators may cause damage to the eardrum. Attempting to block the ear with a finger to prevent medication from escaping is ineffective and may lead to increased pressure in the ear canal. The nurse should gently massage and apply light, not moderate, pressure to the tragus.

After administering a nebulizer treatment containing a steroid, the nurse should give the patient which instruction? A. Monitor for the common adverse effect of bruising. B. Remain NPO (nothing by mouth) for the next hour. C. Rinse the nebulizer with tap water. D. Rinse the mouth and gargle with warm water.

D. Rinse the mouth and gargle with warm water. After a treatment with nebulized steroids, the patient should rinse the mouth and gargle with warm water to remove medication residue from the oral cavity and to prevent thrush. An empty stomach is not required after taking nebulized steroids. The nebulizer is cleaned per manufacturer's guidelines with a disinfectant and rinsed with sterile water after use to minimize bacterial growth. Tap water alone is not sufficient and may contain bacteria. Bruising may be an adverse effect of oral steroids, not inhaled steroids.

How does the nurse correctly administer an intradermal injection for a TB skin test? A. Use a 1-inch (2.5-cm) needle. B. Inject at a 45-degree angle to ensure proper placement of the medication. C. Select a 22-G needle. D. Select a site on the palm-side of the forearm about 2 to 4 inches below the elbow.

D. Select a site on the palm-side of the forearm about 2 to 4 inches below the elbow. A site that is 2 to 4 inches below the elbow on the palm side of the forearm and free of bruises, inflammation, or edema is selected for intradermal injection. Intradermal injection sites should be free of discoloration or hair so results of a skin test can be seen and interpreted correctly. A TB syringe is used with a short needle; a 1-inch needle is too long. A 22-G needle is too large for an intradermal injection; a 27-G needle should be used. Intradermal injections are given slowly at a 5- to 15-degree angle; a 45-degree angle is often used for subcutaneous injections.

Patient education after suprapubic catheter insertion should always include which topic? A. Instruction to limit fluid intake to decrease the stress on the catheter B. How to flush the catheter if obstruction is suspected C. How to perform urethral self-catheterization D. Signs and symptoms of infection

D. Signs and symptoms of infection Patients should be taught about the signs and symptoms of infection that may result from a suprapubic catheter (these include fever, redness, warmth, or malodorous, purulent drainage at the insertion site; malodorous, cloudy, brown, or bloody urine; abdominal pain; or decreased urine output) so that they can report any signs or symptoms to the practitioner. Patients should not limit fluid intake; they should be encouraged to drink at least 2000 ml of fluid a day (if no fluid restriction) because the small-bore suprapubic catheter can easily become obstructed by clots, mucus, or sediment. If the catheter becomes obstructed, patients are advised to call a urologist immediately. Patients should never flush or remove the catheter by themselves. Urethral self-catheterization is no longer necessary with a suprapubic catheter in place.

The nurse is teaching a 21-year-old patient how to use an MDI correctly. What is the evidence that the patient understands the nurse's instructions? A. The patient does not shake the canister. B. The patient presses the canister before taking a breath. C. The patient takes another puff of medication quickly after the first dose. D. The patient holds breath for up to 10 seconds after inhalation.

D. The patient holds breath for up to 10 seconds after inhalation. Holding one's breath for up to 10 seconds allows the medication to reach the deep branches of the airways. Shaking the inhaler before administration is the correct procedure; it mixes the medication in the canister. The correct procedure is to depress the canister while inhaling. A wait of 1 minute is advised between doses of the same medication; a wait of 2 to 5 minutes is the standard between doses of different medications.

After removing an indwelling catheter, which finding would be cause for concern for the nurse? A. Urethral meatus is free of secretions. B. Patient verbalizes feeling of comfort after procedure is completed. C. Patient experiences discomfort when urinating. D. Urethral irritation is present.

D. Urethral irritation is present. Performed correctly, catheter removal should not result in urethral irritation. After the catheter is removed, the patient should be able to void without discomfort. The urethral meatus should be free of secretions and encrustation (or, if present at time of catheter removal, cleansed at that time). The patient should verbalize a feeling of comfort after the procedure is completed, not discomfort.