PN 2006 Final
What should you do if you are administering a soapsuds enema and the patient complains of abdominal pain?
Slow the rate of infusion
At 7 o'clock the patient's glucose is at 7.2. After lunch. the patient drops to 2.2. What should the nurse do?
Start hypoglycemic protocol set by facility
What medication is used for mild musculoskeletal pain
Tylenol / acetaminophen
A 98-year-old patient weighs 95 pounds and needs an intramuscular injection. What site should the nurse use?
Ventrogluteal
The nurse recognizes that which angle of injection is used for an intradermal injection? a. 15 degrees b. 30 degrees c. 45 degrees d. 90 degrees
a. 15 degrees
The nurse is teaching a patient how to calculate how long the metered-dose inhaler (MDI) canister can be used. If the canister contains 200 puffs and the patient administers 2 puffs three times each day, how long will the canister last? a. 33 days b. 34 days c. 66 days d. 100 days
a. 33 days
The nurse assists the health care provider during the insertion of a central venous catheter. Which is the most effective intervention for the nurse to implement to prevent patient infection? a. Adhere to the principles of surgical asepsis. b. Close the door of the sterile procedure room. c. Sterilize working surfaces for the procedure. d. Restrict foot traffic into sterile procedure room.
a. Adhere to the principles of surgical asepsis.
The nurse is caring for a Hindu patient receiving hospice care. Which does the nurse expect to facilitate for the family when the patient dies? a. Allowing the family members to wash and prepare the patient's body b. Helping the family arrange for burial of the body c. Communion and prayers by any type of minister or priest d. Discussion of the finality of death
a. Allowing the family members to wash and prepare the patient's body
When giving subcutaneous Heparin, what other injections should you avoid and why?
Intramuscular injections Bruising
What's a frequent symptom of chronic pain?
Depression
How much space should you leave between the tip of the penis and the condom catheter?
1-2 cm
Gastric pH for nasogastric tube
5 or lower
The client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (antinausea) medication. The nurse recognizes that which of the following statements is true about this medication? a. An enteric-coated medication should be given. b. Medication will not be absorbed as easily because of the nausea. c. A parenteral route is the route of choice. d. A rectal suppository must be administered.
C. A parenteral route is the route of choice
The nurse provides postmortem care for an unfamiliar patient. Which approach should the nurse use to best care for the body after death? a. Ask about the patient's cultural or spiritual practices. b. Remove tubes and lines before they become difficult to remove. c. Cover the patient and transfer the body to the morgue. d. Remove the old patient identification (ID) band and apply a new one.
a. Ask about the patient's cultural or spiritual practices.
The nurse helps the health care provider get supplies and monitor the patient during an emergency insertion of a femoral line at the patient's bedside. Which nursing behavior helps to maintain the sterile environment? a. Avoid reaching over the field. b. Wear a sterile cap and booties. c. Use sterile examination gloves. d. Place a face mask on the patient.
a. Avoid reaching over the field.
The nurse works in a small rural hospital with a wide variety of clients. Of the clients admitted this afternoon, the nurse recognizes that the individual with which of the following conditions is most susceptible to infection? a. Burns b. Diabetes c. Pulmonary emphysema d. Peripheral vascular disease
a. Burns
Which of the following is a priority for the nurse in the administration of oral medications and prevention of aspiration? a. Checking for a gag reflex b. Allowing the client to self-administer c. Assessing the ability to cough d. Using straws and extra water for administration
a. Checking for a gag reflex
The nurse is caring for a patient who is dying. What should the nurse understand about grief that can facilitate family grieving? a. Grief can begin long before the patient actually dies. b. The family needs to say good-bye to the patient. c. Update the family on every patient change. d. Provide a list of the area funeral homes and available services.
a. Grief can begin long before the patient actually dies.
The nurse is getting ready to provide a sterile dressing change. Which nursing action is consistent with principles used to prepare a sterile field? a. Identify that items below waist height are contaminated. b. Use opened packages of dressing supplies within the same shift. c. Identify that sterile drapes have a 5.08 cm 2-inch contaminated border. d. Replace bottle caps if the inside of the cap is not touched.
a. Identify that items below waist height are contaminated.
The nurse is teaching a patient to self-administer insulin. The patient is 5 feet tall and weighs 197 pounds. Which of the following does the nurse include in patient teaching? a. Insert the needle into abdominal tissue at 90-degree angle. b. Include an air space when drawing up the prescribed dose. c. Aspirate before injecting to ensure that the needle is not in a vessel. d. Instruct the patient to use an insulin syringe with a 1-inch needle.
a. Insert the needle into abdominal tissue at 90-degree angle.
Which one of the following indicates that the nurse is using surgical aseptic technique? a. Inserting an intravenous catheter b. Placing soiled linen in moisture-resistant bags c. Disposing of syringes in puncture-proof containers d. Washing hands before changing a dressing
a. Inserting an intravenous catheter
During postmortem care the patient's family says that the patient didn't have his dentures to place in his mouth. Which action should the nurse take at this time? a. Place a rolled-up towel under the patient's chin. b. Stuff the mouth with cotton to maintain the facial contour. c. Tell the family to take the dentures to the funeral home. d. Ask the family what they want to do about this situation.
a. Place a rolled-up towel under the patient's chin.
The nurse is preparing to give a patient a mini infusion administration. What is the safest action for the nurse to take? a. Prime the tubing with medication before attaching it to the patient. b. Obtain a second intravenous (IV) site where the mini infusion will be administered. c. Ask the patient his or her preference about starting a new IV line. d. Consult with the health care provider to obtain the best approach.
a. Prime the tubing with medication before attaching it to the patient.
The nurse evaluates the handwashing technique of nursing assistive personnel (NAP). Which behavior by NAP requires additional training by the nurse? a. Rubs sudsy hands for 5 to 10 seconds b. Uses warm running water and soap c. Dries the hands from the fingers to the wrists d. Keeps the hands and forearms below the elbows
a. Rubs sudsy hands for 5 to 10 seconds
The nurse instructs a patient's partner to administer subcutaneous regular Humulin insulin. What information should the nurse include in the partner's teaching? a. Select a 25-gauge, 5/8-inch needle. b. Massage the site after the injection. c. Always insert the needle at a 45-degree angle. d. Use a different injection site each time.
a. Select a 25-gauge, 5/8-inch needle.
A 3-year-old child is to receive an iron preparation orally. Which of the following actions should the nurse take? a. Use a straw. b. Administer the medication by injection. c. Mix the medication in water. d. Ask the pharmacy to send up a pill for the child to swallow.
a. Use a straw.
The nursing assistant is learning how to use protective equipment when caring for a client in isolation. The nursing assistant is instructed in the correct sequence for putting on the protective equipment. Which of the following describes the correct sequence? a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves. b. Apply the mask and eyewear, put on the gown, wash her hands, and then apply gloves. c. Wash her hands, put on the gown, apply gloves, and then put on mask and eyewear. d. Put on the gown, apply the mask and eyewear, wash her hands, and then apply gloves.
a. Wash her hands, apply the mask and eyewear, put on the gown, and then apply gloves.
What is lorazepam?
anxiolytic
The nurse is working on the pediatric unit. In preparing to give medications to a preschool-age child, which of the following is an appropriate interaction by the nurse? a. "Do you want to take your medication now?" b. "Would you like the medication with water or juice?" c. "Let me explain about the injection that you will be getting." d. "If you don't take the medication now, you will not get better."
b. "Would you like the medication with water or juice?"
A client on the medical unit receives regular insulin at 7:00 A.M. The nurse is alert to a possible hypoglycemic reaction by which time? a. 7:30 A.M. b. 10:00 A.M. c. 4:00 P.M. d. 8:00 P.M.
b. 10:00 A.M.
The nurse is irrigating a wound with a wide opening. What equipment would be appropriate for the nurse to use? a. A 10-mL syringe with a 20-gauge needle b. A 35-mL syringe with a 19-gauge Angio catheter c. A 50-mL syringe with a 27-gauge needle d. A 60-mL syringe with a 24-gauge Angio catheter
b. A 35-mL syringe with a 19-gauge Angio catheter
The nurse is evaluating the integrity of the ventrogluteal injection site. How does the nurse find the site? a. By locating the middle third of the lateral thigh b. By locating the greater trochanter, anterior iliac spine, and iliac crest c. By locating the anterior aspect of the upper thigh d. By locating the acromion process
b. By locating the greater trochanter, anterior iliac spine, and iliac crest
The client requires a sterile dressing change. Which of the following is an appropriate intervention for the nurse to implement in maintaining sterile asepsis? a. Put sterile gloves on before opening sterile packages. b. Check integrity of sterile packages prior to use. c. Place the cap of the sterile solution well within the sterile field. d. Place sterile items on the very edge of the sterile drape.
b. Check integrity of sterile packages prior to use.
The nurse suspects that an older adult client may have pneumonia. Older adult clients may react differently to infectious processes, so the nurse is alert to atypical signs and symptoms, such as which one of the following? a. Hypotension b. Confusion c. Erythema d. Chills
b. Confusion
The nurse is caring for a patient who just died. Which action should the nurse take first to obtain consent for organ and tissue donation? a. Delegate the task to nursing assistive personnel (NAP). b. Determine the patient's legal representative. c. Request a copy of the patient's driver's license. d. Ask the spouse to sign an organ donation consent.
b. Determine the patient's legal representative.
The nurse prepares to administer a 3-mL intramuscular (IM) injection of an antibiotic to an 85-year-old patient. What action does the nurse take to administer the medication correctly? a. Prepares the patient for a subcutaneous injection b. Divides the injection into two separate syringes c. Positions the patient for injection in the dorsogluteal area d. Avoids aspirating when injecting in the deltoid muscle
b. Divides the injection into two separate syringes
The patient is in the final stage of dying. Which action does the nurse implement? a. Maintain a darkened, cool room. b. Elevate the head of the bed. c. Catheterize the patient frequently. d. Provide warm, soothing liquids.
b. Elevate the head of the bed.
A patient is admitted to the emergency department after a motor vehicle accident. The nurse sustains an accidental needlestick injury while performing a venipuncture on the patient. What is the nurse's priority? a. Determine whether the needle was sterile. b. Follow agency policy for employee injuries. c. Inform the provider to screen the patient for antibodies. d. Obtain patient history of communicable diseases.
b. Follow agency policy for employee injuries.
The nurse is caring for a patient who is dying but is receiving palliative care. What reason should the nurse give to the patient's family for this type of care? a. It eliminates all adverse symptoms. b. It improves the patient's quality of life for the time that remains. c. It increases the daily caloric and fluid intake. d. It improves the amount of activity tolerated.
b. It improves the patient's quality of life for the time that remains.
The nurse evaluates the patient's ability to self-administer a subcutaneous injection of the anticoagulent enoxaparin (Lovenox). What action by the patient indicates a need for additional patient teaching? a. Insert the needle at a 45- to 90-degree angle. b. Massage the area after performing the injection. c. Administer the injection without aspirating. d. Inject at least 7.6 cm (3 inches) from the umbilicus.
b. Massage the area after performing the injection.
A patient's family member tells the nurse that she is afraid of hurting the patient when giving the eardrops since she hasn't seen it done. Which action should the nurse take first? a. Observe caregiver administration of eardrops. b. Provide a demonstration of eardrop instillation. c. State that eardrop instillations do not injure ears. d. Agree that instillation of eardrops is challenging.
b. Provide a demonstration of eardrop instillation.
The nurse plans nonpharmacological comfort measures for a patient who is dying. What activity should the nurse include for this type of comfort? a. Keep the head of the bed lowered. b. Provide regular hygiene and skin care. c. Reduce the amount of analgesics given. d. Offer foods and liquids with strong aromas.
b. Provide regular hygiene and skin care.
The nurse is preparing to administer eardrops to a 5-year-old child. Nursing care is appropriate if which technique is used by the nurse? a. Warm the eardrops in a microwave oven on low. b. Pull the auricle upward and outward. c. Apply eardrops to a cotton ball and insert them in the affected ear. d. Instruct the child to lie with the affected ear on a warm compress.
b. Pull the auricle upward and outward.
The nurse is preparing to administer eardrops to a 28-month-old child. Nursing care is appropriate if which technique is used by the nurse? a. Warm the eardrops in a microwave oven on low. b. Pull the pinna down and straight back. c. Apply the eardrops to a cotton ball and insert in the affected ear. d. Instruct the child to lie with the affected ear on a warm compress.
b. Pull the pinna down and straight back.
The nurse is preparing a sterile field with several items on it. Which action should the nurse implement to maintain a sterile field? a. Flip sterile objects onto the sterile field. b. Put fluid holders near the edge of the field. c. Wear sterile gloves to open sterile packs. d. Open the inner flaps of the sterile packages first.
b. Put fluid holders near the edge of the field.
The nurse needs to document a medication that has just been administered. Which technique should the nurse use to document medication administration? a. Document the medication immediately before administration. b. Record the time administered and the nurse's name immediately after administration. c. Record medication administration time, route, and dose at the end of the shift. d. Delegate recording administration time and the nurse's name in the medication administration record (MAR).
b. Record the time administered and the nurse's name immediately after administration.
The nurse instructs the patient about applying a transdermal patch. Which should the nurse include in patient teaching? a. Choose a site with moderate exposure to the sun. b. Remove the old patch before applying a new patch. c. Put the new patch at the same site to promote even absorption. d. Apply a warm compress to the site before application.
b. Remove the old patch before applying a new patch.
The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure? a. Uses a sterile towel to cover the existing holes b. Replaces the entire sterile field and the supplies c. Moves the sterile supplies to a replacement drape d. Avoids using any of the sterile items near the holes
b. Replaces the entire sterile field and the supplies
The nurse is preparing medications for a patient who cannot swallow pills. Nursing care would be correct if the nurse crushes which solid medication? a. Capsule b. Scored tablet c. Enteric-coated tablet d. Buccal tablet
b. Scored tablet
The nurse is caring for a patient who died as a result of an inflicted trauma, even though vigorous resuscitative efforts were taken. Which information should the nurse include when preparing the family to see the deceased patient? a. Some tubes will be left in since the body is now a coroner's case. b. State law requires an autopsy for a coroner's case. c. Organ and tissue donation is impossible after autopsy. d. Families can decline the autopsy for religious reasons.
b. State law requires an autopsy for a coroner's case.
The family wants to see their family member who has just died. What actions by the nurse should be undertaken when the family comes to visit? a. Provide hygienic care, including hair care, in their presence. b. Tell the family to ask any questions that they have about the patient. c. Place the patient's valuables in the body bag to accompany the patient to the morgue. d. Share past experiences of grief with the family so they understand that what they are feeling is not unique.
b. Tell the family to ask any questions that they have about the patient.
The nurse assesses a patient with a surgical incision. What is an expected patient outcome on the fourth postoperative day? a. The tympanic temperature is 39.5° C at 8 AM and noon. b. The incision is slightly reddened and swollen without drainage. c. The skin is spongy and warm around the incision. d. The patient's pain has been increasing gradually.
b. The incision is slightly reddened and swollen without drainage.
The client has a large, deep abdominal incision that requires a dressing. The incision is packed with sterile 1.75-cm packing and covered with a dry, 10 × 10-cm gauze. When changing the dressing, the nurse accidentally drops the packing onto the client's abdomen. Which of the following actions should the nurse take? a. Add alcohol to the packing and insert it into the incision. b. Throw the packing away, and prepare a new one. c. Pick up the packing with sterile forceps, and gently place it into the incision. d. Rinse the packing with sterile water, and put the packing into the incision with sterile gloves.
b. Throw the packing away, and prepare a new one.
The nurse is helping a dyspneic older adult with severe arthritis of the hands and feet to use a nebulizer for respiratory medications. Nursing care would be correct if the nurse takes which action during the medication administration? a. Instructs the patient to hold the mouthpiece with the hands b. Uses a mask to deliver the ordered medication c. Places the patient in a supine position for the treatment d. Has the patient drink some fluid before the treatment
b. Uses a mask to deliver the ordered medication
The patient is in isolation in a negative-pressure room for active tuberculosis. He coughs and spews large amounts of blood-tinged sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self-protection while providing nursing care? a. Cover the patient's mouth and nose snugly with a surgical mask. b. Wear an N-95 mask, gloves, face shield, and isolation gown. c. Place tissues and a contaminated waste container within reach. d. Use a properly fitted surgical mask and gloves to help with tissues.
b. Wear an N-95 mask, gloves, face shield, and isolation gown.
The physician has ordered 6 mg morphine sulphate every three to four hours prn for a client's postoperative pain. The unit dose in the medication dispenser has 15 mg in 1 mL. How much solution should the nurse give? a. 1.5 mL b. 1.3 mL c. 0.4 mL d. 1.25 mL
c. 0.4 mL
The nurse is reviewing the records of four patients on heparin therapy. Which patient does the nurse determine has the highest risk for a bleeding disorder during heparin therapy? a. A 10-year-old patient with an acute viral infection b. A female patient who gave birth over 6 weeks ago c. A patient who takes a nonsteroidal antiinflammatory drug d. A 60-year-old patient with kidney stones
c. A patient who takes a nonsteroidal antiinflammatory drug
The nurse is preparing to give an injection in the ventrogluteal injection site. Which pair of anatomical landmarks does the nurse use for this site? a. Greater trochanter and knee b. Acromion process and axilla c. Anterior superior iliac spine and iliac crest d. Posterior superior iliac spine and iliac crest
c. Anterior superior iliac spine and iliac crest
The nurse prepares medication for a patient 1 hour after admission. What information about the patient is the nurse's priority assessment before the initial administration of medication? a. The diet history b. Any drug tolerance c. Any allergy history d. The surgical history
c. Any allergy history
The nurse prepares to administer artificial tears to the patient's eyes twice daily. Which should the nurse implement when administering the patient's eyedrops? a. Dispense the eyedrops to the inner corner of each eye. b. Call the provider for clarification of this order. c. Check the patient identifiers before administration. d. Determine the patient's history of taking this medication.
c. Check the patient identifiers before administration.
A medication is prescribed for the client and is to be administered by intravenous (IV) bolus injection. Which of the following is a priority for the nurse before administering the medication via this route? a. Set the rate of the IV infusion. b. Check the client's mental alertness. c. Confirm placement of the IV line. d. Determine the amount of IV fluid to be administered.
c. Confirm placement of the IV line.
The nurse is documenting administration of a medication that is given at 10:00 A.M., 2:00 P.M., and 6:00 P.M. Which of the following medications is the nurse documenting? a. Morphine sulphate, 10 mg q4h prn b. Propranolol (Inderal), 10 mg PO bid c. Diazepam, 5 mg PO tid d. Cephalexin (Keflex), 500 mg PO q8h
c. Diazepam, 5 mg PO tid
The nurse is preparing to assist with a sterile procedure in the surgical suite. Which of the following is an appropriate technique that the nurse includes in the surgical scrub? a. Keeping the hands below the elbows throughout the scrub b. Using a brush on the palms and dorsal surface of the hands c. Maintaining a scrub for two to six minutes d. Washing well around all artificial nails
c. Maintaining a scrub for two to six minutes
The nurse wants to provide specialized nursing care for a patient with a serious degenerative illness that is not life threatening but for which there is no cure. Which approach would the nurse use in the care of this patient? a. Hospice care b. A combination of hospice care and palliative care c. Palliative care d. Experimental curative therapy with hospice care
c. Palliative care
The nurse prepares to administer cyclosporine (Restasis) eyedrops to a patient with dry eyes. Which of the following actions should the nurse implement before instilling the eyedrops? a. Apply mild pressure on the entire eye. b. Apply the eye ointment along inner edge of lower eyelid. c. Remove any periorbital crusting with a warm face cloth. d. Wipe away any crusting from the outer to the inner canthus.
c. Remove any periorbital crusting with a warm face cloth.
The nurse prepares to change the patient's dressing using sterile technique. Which does the nurse implement to promote infection control? a. Scrubs the drain insertion site in a back-and-forth manner b. Cleans the incision from wound edges toward the center c. Removes the old dressing with clean gloves; inspects the wound d. Dons sterile gloves, removes the dressing, and opens sterile supplies
c. Removes the old dressing with clean gloves; inspects the wound
The nurse assigns patient care to nursing assistive personnel (NAP). Which wound care tasks should the nurse assign to NAP? a. Applying a hydrocolloid dressing b. Assessing the dimensions of the wound c. Reporting visible drainage on dressing d. Changing the first postoperative dressing
c. Reporting visible drainage on dressing
The nurse completes preparation of the sterile field to change a patient's dressing when the patient's dinner tray arrives. Which action should the nurse take? a. Use the sterile field on another patient in another room. b. Change the dressing using clean technique to save time. c. Set the tray aside and proceed with the dressing change. d. Cover the setup with a sterile drape and let the patient eat.
c. Set the tray aside and proceed with the dressing change.
The nurse is preparing to administer the anticoagulant enoxaparin (Lovenox) subcutaneously. Which injection site is most appropriate for the nurse to use? a. Thighs b. Deltoid area c. Sides of abdomen d. Ventrogluteal area
c. Sides of abdomen
The nurse applies Steri-Strips to the patient's surgical site after suture removal. During patient teaching, what does the nurse instruct the patient to avoid doing? a. Limit heavy lifting activities. b. Ambulate several times a day. c. Soak in the bathtub for relaxation. d. Use a pillow to support the incision.
c. Soak in the bathtub for relaxation.
The family of the patient receiving hospice care is at the bedside expecting an imminent death. They become upset when the patient suddenly becomes restless and disoriented. Which should the nurse implement as the patient advocate? a. Apply oxygen with a face mask. b. Ask the family to leave the room. c. Speak to the patient calmly and softly. d. Administer extra pain medication.
c. Speak to the patient calmly and softy
The patient has a scored white tablet, a capsule, buccal medication, and an enteric-coated tablet. Which medication should the nurse administer last? a. The scored white tablet b. The capsule c. The buccal medication d. The enteric-coated tablet
c. The buccal medication
The nurse recognizes the appropriate procedures for sterile asepsis. Of the following, which action is consistent with sterile asepsis? a. Clean forceps may be used to move items on the sterile field. b. Sterile fields may be prepared well in advance of the procedures. c. The first small amount of sterile solution should be poured and discarded. d. Wrapped sterile packages should be opened starting with the flap closest to the nurse.
c. The first small amount of sterile solution should be poured and discarded.
The patient wants to receive insulin by continuous subcutaneous injection (CSCI). Which injection site does the nurse suggest for the patient? a. The upper arm b. The upper chest c. The lower abdomen d. The thigh
c. The lower abdomen
Which angle should the nurse use to administer an intramuscular (IM) injection for a patient who is 5 feet 6 inches tall and weighs 140 pounds? a. 15 degrees b. 45 degrees c. 60 degrees d. 90 degrees
d. 90 degrees
An order is written for meperidine (Demerol), 500 mg IM q3-4h prn for pain. The nurse recognizes that this is significantly more than the usual therapeutic dose. Which of the following actions should the nurse take? a. Give 50 mg IM as it was probably intended to be written. b. Refuse to give the medication and notify the nurse manager. c. Administer the medication and watch the client carefully. d. Call the prescriber to clarify the order.
d. Call the prescriber to clarify the order.
Which of the following is the most effective way in the acute care environment to determine the client's identity before administering medications? a. Ask the client's name. b. Check the name on the chart. c. Ask the other caregivers. d. Check the client's name band.
d. Check the client's name band.
The nurse approaches a group of patients, one of whom is to receive a dose of medication. Which is the best method for the nurse to identify the patient needing the medication? a. Question the entire group by calling for the specific patient. b. Request that the other patients identify the patient. c. Ask the patients who is scheduled to receive medications now. d. Compare the patients' identification bracelets with the specific medication administration record (MAR) and ask the patient to state his name.
d. Compare the patients' identification bracelets with the specific medication administration record (MAR) and ask the patient to state his name.
The nurse is administering an injection at the ventrogluteal site. Upon aspiration, the nurse notices that there is blood in the syringe. Which of the following actions should the nurse take? a. Inject the medication. b. Pull the needle back slightly and inject the medication. c. Move the skin to the side and inject the medication slowly. d. Discontinue the injection and prepare the medication again.
d. Discontinue the injection and prepare the medication again.
The nurse instructs a patient with diabetes mellitus about subcutaneous insulin administration. What does the nurse include in patient teaching? a. Remember that NPH insulin peaks within 15 minutes. b. Prepare for hyperglycemia 2 hours after taking insulin. c. Keep insulin refrigerated after administering the first dose. d. Eat right after taking regular insulin to avoid hypoglycemia.
d. Eat right after taking regular insulin to avoid hypoglycemia.
A patient is to receive three medications via an enteral feeding tube. What action by the nurse best contributes to maintaining the patency of the tube? a. Pouring the medications slowly into the tube b. Checking the gastric residual volume before feeding c. Elevating the head of the bed at least 45 degrees d. Flushing the tube between medications and after the last one
d. Flushing the tube between medications and after the last one
The nurse is preparing to put on sterile gloves. What should the nurse do to begin this procedure? a. Pull the first glove up and over the nondominant hand. b. Place the fingers of the dominant hand under the cuff of the first glove. c. Let the cuff of the glove roll up over the hand for more coverage. d. Hold the inside surface of the first glove to pull over the hand.
d. Hold the inside surface of the first glove to pull over the hand.
The client is to receive heparin by injection. Where does the nurse prepare to inject this medication? a. In the client's scapular region b. In the client's vastus lateralis c. In the client's posterior gluteal area d. In the client's abdomen
d. In the clients abdomen
The nurse needs to administer a rectal suppository to a patient for constipation. Which action may the nurse delegate to the nursing assistive personnel (NAP)? a. Inserting the suppository into patient's rectum b. Notifying the patient's health care provider of the suppository results c. Documenting the administration of a suppository after insertion d. Informing the nurse of the bowel movement
d. Informing the nurse of the bowel movement
The nurse is teaching the client how to prepare 10 units of short-acting (regular) insulin and 5 units of intermediate-acting NPH insulin for injection. Which of the following instructions does the nurse give the client? a. Inject air into the short-acting (regular) insulin, then into the intermediate-acting NPH insulin. b. Withdraw the short-acting (regular) insulin first. c. Inject air into and withdraw the intermediate-acting NPH immediately. d. Inject air into both vials and withdraw the short-acting (regular) insulin first.
d. Inject air into both vials and withdraw the short-acting (regular) insulin first.
The nurse administers intradermal injections for allergy testing. Which is the best technique for the nurse to use for skin testing? a. Select a 22-gauge needle. b. Inject at a 45-degree angle. c. Choose the back for the first test. d. Inject below the antecubital space.
d. Inject below the antecubital space.
The nurse's outcome for the patient is, "Patient self-administers subcutaneous heparin before discharge." What does the nurse include in patient teaching? a. Expect large areas of bruising around the injection site. b. Promote heparin absorption by massaging the injection site. c. Choose one large area for consistent heparin absorption. d. Inject heparin into the abdomen but avoid the umbilical area.
d. Inject heparin into the abdomen but avoid the umbilical area.
The nurse prepares to administer acetaminophen (Tylenol) 650 mg rectally. Which does the nurse implement to administer the suppository properly? a. Assists the patient to right lateral position and flexes the left leg b. Performs a preadministration digital rectal examination c. Washes hands and applies sterile gloves before the procedure d. Inserts the suppository 10 cm (4 inches) into the patient's rectum
d. Inserts the suppository 10 cm (4 inches) into the patient's rectum
A toddler is to receive an intramuscular injection. What action can the nurse take to make the injection less traumatic? a. Have the parents hold the toddler down during the injection. b. Collaborate with the health care provider about what to do. c. Encourage the toddler to move the leg after the injection. d. Obtain an order for EMLA cream or vapo-coolant spray.
d. Obtain an order for EMLA cream or vapo-coolant spray.
While cleaning a wound, the nurse determines that undermining is at the top of the wound. Which documentation of the wound by the nurse is best? a. Dark pink wound with undermining at 2 o'clock b. Wound clean and without odor with slight undermining toward patient's head c. See photograph of wound taken today d. Pale pink wound 2 cm ´ 3 cm ´ 2 cm deep with undermining at 12 o'clock
d. Pale pink wound 2 cm ´ 3 cm ´ 2 cm deep with undermining at 12 o'clock
The nurse is teaching a patient to self-administer subcutaneous heparin at home. What does the nurse include in patient teaching? a. Use a 22-gauge, 1-inch needle for the heparin injections. b. Change needles after withdrawing the heparin from the vial. c. Instruct the patient and family to recap all needles used at home. d. Pinch a large area of skin and inject heparin into the center of the skin fold.
d. Pinch a large area of skin and inject heparin into the center of the skin fold.
The nurse is caring for a patient who is 4 years old and in isolation. Which approach should the nurse implement to reduce the patient's anxiety? a. Put the child in a room with a locked door. b. Ask the parents to keep the child in the room. c. Explain isolation to the child by using a cartoon. d. Put the mask, gown, and gloves on in view of the child.
d. Put the mask, gown, and gloves on in view of the child.
While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. Which reaction allows the nurse to maintain safe practice? a. Inspect the package for tears. b. Brush away the visible debris. c. Record the procedure as clean. d. Replace the sterile package.
d. Replace the sterile package.
When administering an intramuscular (IM) injection, the nurse obtains blood during aspiration. What action by the nurse is appropriate? a. Wait 30 minutes before giving the ordered medication. b. Notify the health care provider of the situation. c. Continue to administer the ordered medication. d. Stop the administration and discard the syringe.
d. Stop the administration and discard the syringe.
The nurse is performing a wound assessment after removing the soiled dressing. What finding would indicate a problem requiring additional assessment? a. An incisional ridge continues to be present. b. The patient experiences less discomfort. c. There is a lack of new drainage. d. The patient states, "My wound feels warm."
d. The patient states, "My wound feels warm."
The nurse plans care for the patient who has asthma and receives albuterol nebulizer therapy. The patient's respiratory rate is 34 breaths per minute, and breath sounds reveal wheezing throughout both lung fields. Which outcome is the nurse's priority for this patient within 24 hours? a. The patient self-administers the medication using the nebulizer. b. The patient correctly describes the use of a small-volume nebulizer. c. The patient recites side effects and clinical indicators to report. d. The patient's respiratory rate falls below 28 breaths per minute.
d. The patient's respiratory rate falls below 28 breaths per minute.
The nurse is caring for a 14-year-old patient with diabetes mellitus who does not want to self-administer insulin because it is too painful. Which information should the nurse use in response to the patient's concern? a. Adolescents are usually enthusiastic about self-care. b. Insulin mixed with a local anesthetic decreases pain. c. The health care provider orders oral insulin for patients with pain. d. There are techniques that will minimize the pain of the injection, though not eliminate it.
d. There are techniques that will minimize the pain of the injection, though not eliminate it.
The nurse prepares an IM injection to administer a medication available in a glass ampule. Which step does the nurse take to administer the injection properly? a. Labels the ampule with date and time of the first dose b. Ensures that the cartridge is fully seated into the syringe c. Cleans the rubber top carefully before inserting the needle d. Uses a filter needle to withdraw the contents of the ampule
d. Uses a filter needle to withdraw the contents of the ampule
The nurse needs to administer an intramuscular (IM) injection to a patient who is 7 months old. Which is the best site for the nurse to use for the injection? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Vastus lateralis
d. Vastus lateralis
