N305: EXAM 2 Saunders/Evolve

The nurse is caring for a pediatric client who is going to receive a vaccination. Place the nursing actions for performing this procedure in order of priority. All options must be used: 1.Assess for allergies. 2.Verify the prescription. 3.Check the lot number and expiration. 4.Obtain parental consent. 5.Provide a vaccination record to the parents. 6.Select appropriate site and administer the vaccine.

2,1,4,3,6,5

The nurse is reviewing the instillation technique for both eye ointment and eye drops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which statement made by the parent would indicate that learning has taken place? a. "I will be careful not to touch the eye or eyelid during administration." b. "I will place my child on the left side to administer drops in the right eye." c. "I will administer the eye ointment and then wait 5 minutes and administer the eye drops." d. "I will have my child blink after the instillation to encourage thorough distribution of the eye drops."

a. "I will be careful not to touch the eye or eyelid during administration."

The nurse is instilling drops into a 3 month old infant's ear. The nurse would take which action to perform this procedure? a. Pull up and back on the earlobe and direct the solution toward the eardrum. b. Pull down and back on the auricle and direct the solution toward the eardrum. c. Pull up and back on the auricle and direct the solution toward the wall of the canal. d. Pull down and back on the earlobe and direct the solution toward the wall of the canal.

d. Pull down and back on the earlobe and direct the solution toward the wall of the canal. The infant needs to be turned onto the side, with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the nurse pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal.

A client is prescribed an eye drop and an eye ointment for the right eye. How would the nurse best administer the medications? a. Administer the eye drop first, followed by the eye ointment. b. Administer the eye ointment first, followed by the eye drop. c. Administer the eye drop, wait 20 minutes, and administer the eye ointment. d. Administer the eye ointment, wait 20 minutes, and administer the eye drop.

a. Administer the eye drop first, followed by the eye ointment. When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 5 to 10 minutes.

The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective? a. "It helps to use magical thinking with the infant-age group. b. "It helps to use magical thinking with the school-age group." c. "It helps to use magical thinking with the toddler-age group." d. "It helps to use magical thinking with the preschool-age group."

d. "It helps to use magical thinking with the preschool-age group." The nurse uses developmental perspectives when administering medications. The preschool age is when the nurse can make use of "magical thinking" as a strategy to administer medications. Infants and toddlers are too young for this concept, and school-age children are too mature.

The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting? Select all that apply. a. Intranasal spray b. Intravenous push c. Oral transmucosal lozenge d. 72-hour transdermal patch e. Fentanyl via a patient-controlled analgesia pump

a. Intranasal spray c. Oral transmucosal lozenge d. 72-hour transdermal patch There are ways to administer fentanyl for chronic pain. They are as follows: 72-hour transdermal patches, oral transmucosal lozenges, and intranasal sprays. Fentanyl administered either by intravenous (IV) push or with a patient-controlled analgesia (PCA) pump is given for acute, not chronic, pain.

The nurse is preparing to administer an oral medication to an infant. In which position would the nurse place the infant? a. Prone b. Semi-Fowler's c. Trendelenburg's d. Dorsal recumbent

b. Semi-Fowler's The nurse would administer oral medications with the infant sitting in an upright position to prevent aspiration if the infant cries or resists. Semi-Fowler's is an upright position. Trendelenburg's position is on the back with the head lowered, and prone is on the abdomen. Oral medications could not be administered to an infant in either of these positions. Dorsal recumbent means on the back and flat, so there would be a risk of aspiration with this position.

Ear drops are prescribed for an infant with otitis media. Which is the most appropriate method to administer ear drops to an infant? a. Pull up and back on the pinna, and direct the solution onto the eardrum. b. Pull down and back on the pinna, and direct the solution onto the eardrum. c. Pull down and back on the pinna, and direct the solution toward the wall of the canal. d. Pull up and back on the pinna, and direct the solution toward the wall of the canal.

c. Pull down and back on the pinna, and direct the solution toward the wall of the canal In a child younger than 3 years of age, the pinna is pulled down and straight back. The infant would be turned on the side with the affected ear uppermost. Using the nondominant hand, the person administering the ear drops pulls the pinna down and back. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant needs to remain with the affected ear uppermost for 10 to 15 minutes to retain the solution. In an adult or a child older than 3 years of age, the pinna is pulled up and back to straighten the auditory canal.

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? a. Ventrogluteal b. Lateral deltoid c. Rectus femoris d. Vastus lateralis

d. Vastus lateralis Intramuscular injection sites are selected on the basis of the child's age and muscle development of the child. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 4-month-old infant. The sites identified in options 1, 2, and 3 are unsafe for a child of this age.

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions would the nurse take before administering the medication? Select all that apply. a. Check the residual volume. b. Aspirate the stomach contents. c. Turn off the suction to the nasogastric tube. d. Remove the tube and place it in the other nostril. e. Test the stomach contents for a pH indicating acidity.

a. Check the residual volume. b. Aspirate the stomach contents. c. Turn off the suction to the nasogastric tube. e. Test the stomach contents for a pH indicating acidity. By aspirating stomach contents, the residual volume can be determined and the pH checked. A pH of less than 4.0 verifies gastric placement. The suction would be turned off before the tubing is disconnected to check for residual volume; in addition, suction needs to remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply. a. The right dose b. The right route c. The right time d. The right client e. The right staff member f. The right documentation

a. The right dose b. The right route c. The right time d. The right client f. The right documentation The rights to administering medications include the right medication, the right client, the right dose, the right route, the right time, right documentation, the right reason for the medication, and the right response to the medication. The right staff member is not a right of medication administration.

The nurse teaching a parent how to administer ear drops to an infant tells the parent to pull the child's ear in which direction? a. Up and back and direct the solution onto the eardrum b. Down and forward and direct the solution onto the eardrum c. Up and forward and direct the solution toward the wall of the canal d. Down and back and direct the solution toward the wall of the canal

d. Down and back and direct the solution toward the wall of the canal The ear is pulled down and straight back in a child younger than 3 years. The infant is turned onto the side, with the affected ear uppermost. The nurse teaches the parent to pull down and back on the earlobe with the nondominant hand while resting the wrist of the dominant hand on the infant's head. The medication is directed toward the wall of the canal rather than onto the eardrum. The infant would lie with the affected ear uppermost for 10 to 15 minutes to retain the solution. In an adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal.

A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action? a. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid b. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid c. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid d. Lies supine with the head turned to one side with the eye to be used uppermost; closes the eye gently, squeezes the drop onto the inner canthus of the eye, and turns from this side to the other while blinking

a. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid It is correct procedure for the client to lie down or sit with the head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that one drop falls into the lower lid. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. With the eye gently closed, the client squeezes the drop onto the inner canthus of the eye. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

A client is in the bathroom when the nurse arrives to administer scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? a. Return to administer the medications when the client is finished in the bathroom. b. Leave the medication at the bedside as the client requested. c. Let another nurse who is not busy give the client the medication when the client is finished in the bathroom. d. Tell the assistive personnel to give the medication when the client is finished in the bathroom.

a. Return to administer the medications when the client is finished in the bathroom. The best action is to tell the client that they will return with the medication once the client is finished in the bathroom. It is inappropriate to leave a medication in a client's room. Another nurse would not administer a medication that they did not prepare. It is not within the scope of practice of an assistive personnel to administer medications.

The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action would the nurse take when performing the procedure? a. Warm the irrigating solution to 98.6° F (37.0° C). b. Position the client with the affected side up following the irrigation. c. Direct a slow, steady stream of irrigation solution toward the eardrum. d. Assist the client to turn the head so that the ear to be irrigated is facing upward.

a. Warm the irrigating solution to 98.6° F (37.0° C). Before ear irrigation, the nurse would inspect the tympanic membrane to ensure that it is intact. The irrigating solution would be warmed to 98.6° F (37.0° C) because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The affected side needs to be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal.

The nurse is preparing to administer eye drops to a client being prepared for cataract surgery. Which actions would the nurse take to administer the drops? Select all that apply. a. Wash hands. b. Put gloves on. c. Place the drop in the conjunctival sac. d. Pull the lower lid down against the cheekbone. e. Instruct the client to squeeze the eyes shut after instilling the eye drop. f. Instruct the client to tilt the head forward, open the eyes, and look down.

a. Wash hands. b. Put gloves on. c. Place the drop in the conjunctival sac. d. Pull the lower lid down against the cheekbone. To administer eye medications, the nurse would wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy? a. Constipation because of the location of the epidural catheter b. Dislodgment of the epidural catheter because the catheter is not sutured in place c. Permanent lower motor weakness because of the proximity of the catheter to the sciatic nerve d. Chronic addiction to the epidural medication because epidural analgesia is a more powerful means of pain relief than patient-controlled analgesia therapy

b. Dislodgment of the epidural catheter because the catheter is not sutured in place Epidural analgesia (also known as peridural or extradural analgesia) refers to the instillation of a pain-blocking agent into the epidural space. Complications that occur with epidural analgesia are directly related to catheter placement, catheter maintenance, and the type of analgesia. Epidural catheters are not sutured in position and must be taped in place to help prevent dislodgment. Low concentrations of medications are used to avoid any sensory and motor deficits that can accompany epidural analgesia. Constipation and chronic addiction are not specific complications of epidural analgesia.

The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action would the nurse perform when administering this test to the client? a. Inject the medication and place a pressure dressing over the medication site. b. Make a circular mark around the injection site after administration of the tuberculin test. c. Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle. d. Massage the area with an alcohol swab after injection to ensure that the medication is absorbed.

b. Make a circular mark around the injection site after administration of the tuberculin test. An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb would form under the skin with injection. After withdrawing the needle, the area may be patted dry with a 2 × 2 sterile gauze pad, but pressure would not be applied. The area would not be rubbed because this will cause the medication to spread beyond the area of injection. The area of injection is outlined or circled for later reference and interpretation of the results of the test.

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? a. "I need to cuddle my child after giving the medication." b. "I can give my child a frozen juice bar after they swallows the medication." c. "I need to mix the medication in the baby food and give it when I feed my child." d. "If my child does not like the taste of the medicine, I would encourage them to pinch their nose and drink the medication through a straw."

c. "I need to mix the medication in the baby food and give it when I feed my child." The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The parent needs to provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The parent would offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child needs to pinch the nose and drink the medication through a straw.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would take which action? a. Position the client supine to assist in medication absorption. b. Aspirate the nasogastric tube after medication administration to maintain patency. c. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. d. Change the suction setting to low intermittent suction for 30 minutes after medication administration.

c. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. If a client has a nasogastric tube connected to suction, the nurse would wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client would not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription would the nurse question? a. Furosemide 20 mg via PEG tube daily b. Digoxin 0.25 mg via PEG tube daily c. Isosorbide mononitrate ER 30 mg via PEG tube daily d. Acetaminophen elixir 650 mg via PEG every 4 hours as needed for temperature >101° F (>38.3° C)

c. Isosorbide mononitrate ER 30 mg via PEG tube daily The process for administration of medications via PEG tube includes checking for bowel sounds, residual, and placement prior to medication administration. Then the nurse would crush each medication and mix with tap water, administering the medications one at a time followed by a flush in between each medication. Enteric-coated tablets; extended-release tablets, such as isosorbide mononitrate; and controlled-release tablets and capsules would not be crushed because their mechanism of slow release is interrupted.

The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why they are receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication? a. "Your primary health care provider wants you to have it this way." b. "Are you saying that you are not going to take this medication?" c. "Medications given this way have fewer side effects than those given orally." d. "Medications given this way are absorbed more quickly than by other routes."

d. "Medications given this way are absorbed more quickly than by other routes." Medications given parenterally are absorbed more quickly than by other routes. The intramuscular route provides faster medication absorption than the subcutaneous route because of the greater vascularity of the muscle. The remaining options do not answer the client's question and may be belittling or incorrect.

The nurse is preparing to administer an intradermal medication. Which action would the nurse take before administering the medication? a. Cleanse the site of injection with an alcohol swab and fan the alcohol dry. b. Cleanse the site of injection with an alcohol swab and pat it dry with tissue. c. Cleanse the site of injection with an alcohol swab and blow the alcohol dry. d. Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry.

d. Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry. Before administering an intradermal medication, the site of injection is cleaned with an alcohol swab and allowed to dry. The actions in the remaining options are incorrect because they contaminate the site before the administration of the medication.