Senior Practicum Medication and I.V Administration

A client is scheduled for an excretory urography at 10 a.m. (1000). An order directs the nurse to insert a saline lock intravenous (IV) device at 9:30 a.m. (0930). The client requests a local anesthetic for the IV procedure and the primary healthcare provider prescribes lidocaine-prilocaine cream. The nurse should apply the cream at:

8:30 a.m. (0830). Explanation: Lidocaine-prilocaine cream should be applied 1 hour prior to minor dermal procedures, and 2 hours for major dermal procedures. Therefore, if the insertion is scheduled for 9:30 a.m. (0930), lidocaine-prilocaine cream should be applied at 8:30 a.m. (0830) The local anesthetic would not be effective if the nurse administered it at the later times, and would lose effectiveness if applied at 0600.

What is the main advantage of using a floor stock system?

A nurse can implement medication orders quickly. Explanation: A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

When positioned properly, the tip of a central venous catheter should lie in the:

superior vena cava. When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.

A nurse receives a lithium level report of 1.0 mEq/L (1 mmol/L) for a client who has been taking lithium for 2 months. How does the nurse interpret this information?

within the therapeutic range Explanation: For the client who has been receiving lithium therapy for the past 2 months, a maintenance serum lithium level of 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L) is considered therapeutic. A lithium level greater than 1.2 mEq/L (1.2 mmol/L) suggests toxicity.

Which of the following is the priority action the nurse should take when finding medications at a client's bedside?

Remove the medications from the room and discard them into an appropriate disposal bin. Explanation: This answer reflects best practice of nursing and medication administration. Leaving the medications creates a risk for another client to take them, or for them to get lost. Leaving them and seeking the nurse creates a risk for loss or another client taking them. It is incorrect and unsafe to label medications that were taken out by another nurse.

Which information should the nurse include when teaching the family and a client who was prescribed benztropine, 1 mg PO twice daily, about the drug therapy?

The client should not discontinue taking the drug abruptly. Explanation: The nurse should teach the client and family the importance of not discontinuing benztropine abruptly. Rather, the drug should be tapered slowly over a 1-week period. Benztropine should not be used with over-the-counter cough and cold preparations because of the risk of an additive anticholinergic effect. Antacids delay the absorption of benztropine, and alcohol in combination with benztropine causes an increase in central nervous system depression; concomitant use should be avoided.

Which factors influence safe and effective medication administration for elderly clients?

There is less efficient absorption, detoxification, and elimination. Explanation: When giving medications to elderly individuals, consideration needs to be made for physiologic changes associated with aging. There may be poor absorption from the intestines as well as inadequate elimination. In addition, the liver may be inefficient in detoxification. For the elderly, there is an increased risk of drug interactions because of the number of medications prescribed. They could forget to take the meds. There is less likelihood of solubility and distribution.

Which adverse effects occur when there is too rapid an infusion of TPN solution?

circulatory overload Explanation: Too rapid infusion of a TPN solution can lead to circulatory overload. The client should be assessed carefully for indications of excessive fluid volume. A negative nitrogen balance occurs in nutritionally depleted individuals, not when TPN fluids are administered in excess. When TPN is administered too rapidly, the client is at risk for receiving an excess of dextrose and electrolytes. Therefore, the client is at risk for hyperglycemia and hyperkalemia.

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should:

roll the vial gently between her palms. Explanation: Rolling the vial gently between the palms produces heat, which helps dissolve the medication. Stirring the medication with a sterile applicator isn't accepted practice. Inverting the vial wouldn't help dissolve the medication. Shaking the vial vigorously could cause the medication to break down, altering its action.

Two days after a client undergoes repair of a ruptured cerebral aneurysm, a physician orders mannitol, 0.5 g/kg to be infused over 60 minutes. The client weighs 175 lb. The nurse should administer how many grams of mannitol? Record your answer using a whole number.

40 Explanation: To determine the number of grams to administer, the nurse first must convert the client's weight from pounds to kilograms using the following conversion factor: 1 kg = 2.2 lb 175 lb x 1 kg / 2.2 lb = 79.55 kg (pounds cancel out in this equation) 175 lb / 2.2 lb = 79.55 kg Next multiply the client's weight by the ordered amount (0.5 mg / kg). 79.55 kg x 0.5 g/kg = 39.775 g (kilograms cancel out) Round this number to the nearest whole number to determine the dose to be administered equals 40 grams.

A nurse manager notices that a number of medication errors have occurred on the unit with nurses giving hydralazine instead of hydroxyzine. What would be the most appropriate action for the nurse manager?

Consult with pharmacy to ensure distinct labeling of the medications Explanation: Sometimes medication errors increase with drugs that are similar in name. These are sometimes referred to as SALAD names, which refer to sound-alike, look-alike drugs. The pharmacy should be consulted to help determine a way to label each medication that draws attention to the name of the medication.

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required posttest. Explanation: A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not alone assure that the information is read.

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. Explanation: To administer oral medication through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Making sure not to crush sustained-release tablets or empty capsules, she then inserts the liquid into the NG tube. Heating the tablets may destroy or alter the drug's action. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and clogging the tube.

Which assessment findings indicates that epoetin alfa is having a therapeutic effect?

Hemoglobin 12 g/dL Explanation: Epoetin alfa is a colony-stimulating factor used help boost red blood cell count. Indications for use are a hemoglobin level < 10 g/dL. It will not improve white blood cells or components (neutrophils) or platelet counts.

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Hypokalemia Explanation: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

The nurse should teach the client who is receiving warfarin sodium that:

International Normalized Ratio (INR) is used to assess effectiveness. Explanation: INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.

The nurse should instruct a client who is taking dexamethasone and furosemide to report:

muscle weakness. Explanation: The nurse should instruct the client who is taking dexamethasone and furosemide to observe for signs and symptoms of hypokalemia, such as malaise, muscle weakness, vomiting, and a paralytic ileus, because both dexamethasone and furosemide deplete serum potassium. This combination of drugs does not cause the client to become excitable or have diarrhea or thirst.

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should:

question the prescription because gentamicin could cause further hearing impairment. Explanation: Aminoglycoside antibiotics can cause damage to the eighth cranial nerve and result in ototoxicity. If the client is already hearing impaired, the nurse should question the prescription with the health care provider, who may determine that prescribing another antibiotic would be safer. Gentamicin is an appropriate antibiotic for gram-negative infections such as peritonitis. Gentamicin does not cause visual impairment.

To prevent complications associated with TPN administered through a central line, the nurse should:

secure all connections of the system. Explanation: Complications associated with administration of TPN through a central line include infection and air embolism. To prevent these complications, strict aseptic technique is used for all dressing changes, the insertion site is covered with an air-occlusive dressing, and all connections of the system must be secure. Ambulation and activities of daily living are encouraged and not limited during the administration of TPN.

During gentamicin therapy, the nurse should monitor a client's:

serum creatinine level. Explanation: During gentamicin therapy, the nurse should monitor a client's serum creatinine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. The drug doesn't appear to affect serum potassium or glucose levels or PTT.

A woman is taking oral contraceptives. The nurse teaches the client to report which complication?

severe calf pain Explanation: Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.

A client is asking about dietary modifications to counteract the long-term effects of prednisone. What is the most appropriate information for the nurse to give the client?

"Increase your intake of calcium and vitamin D." Explanation: Problems associated with long-term corticosteroid therapy include sodium retention, osteoporosis, and hyperglycemia. An increase in calcium and vitamin D is needed to help prevent bone deterioration. Dietary modifications need to reduce sodium, maintain high protein levels for tissue repair, and reduce carbohydrates, as there is a tendency toward hyperglycemia. Increased intake of complex carbohydrates is not indicated because of hyperglycemia. There should be decreased fat intake because there is a tendency for central fat deposition.

A client who has been taking flunisolide nasal spray, two inhalations a day, for treatment of asthma has painful, white patches in the mouth. What should the nurse tell the client?

"You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent." Explanation: Use of oral inhalant corticosteroids such as flunisolide can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.

The nurse is caring for a client with a nasogastric tube and is preparing to administer the client's medications. Which of the following medications can the nurse safely administer through the tube? Select all that apply.

- A liquid medication - An emptied capsule mixed with water Explanation: A liquid medication and an emptied capsule mixed with water may be safely administered through a nasogastric tube. Crushing an enteric-coated tablet alters the properties of the tablet and the benefit of the enteric coating. Crushing a long-acting medication may cause a toxic dose of medication to be released into the client's system. Administering a sublingual medication through a nasogastric tube may cause inactivation of the medication by stomach acid.

The nurse is caring for a client with an IV line. During care of the IV line, the nurse would be required to wear protective gloves in which of the following situations? Select all that apply.

-When inserting the IV -When discontinuing the IV -When changing the IV site Explanation: The nurse should wear protective gloves when inserting the IV, when discontinuing the IV, and when changing the IV site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.

The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply.

-Write down the prescription. -Repeat the prescription to the HCP over the telephone. - Ask the HCP to confirm that the prescription is correct. Explanation: The nurse should write down the prescription, read the prescription back to the HCP, and receive confirmation from the provider that the prescription is correct as understood by the nurse. It is not necessary for the HCP to come to the hospital to write the prescription on the medical record or to have the nursing supervisor cosign the telephone prescription.

The physician orders 2 teaspoons of an oral laxative as needed for a constipated client. How many milliliters should the nurse administer to the client?

10 Explanation: One teaspoon equals 5 ml. Therefore, to administer the correct amount of medication, the nurse should administer 10 ml.

The nurse is to instill drops of phenylephrine hydrochloride into the client's eye prior to cataract surgery. What is the expected outcome?

dilation of the pupil and constriction of blood vessels Explanation: Instilled in the eye, phenylephrine hydrochloride acts as a mydriatic, causing the pupil to dilate. It also constricts small blood vessels in the eye.

A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication?

"Swallow this medication whole. Do not chew it." Explanation: Digestion begins in the mouth. Pancrelipase needs to be swallowed whole in order to reach the stomach before digestion begins and cannot be crushed, chewed, or held in the mouth. In order for the medication to be effective, it must be taken before meals or snacks. The medication needs to be stored in a dry place but does not require refrigeration.

While providing palliative care to a client in the home setting, the client's family expresses concern that the client is receiving "too much narcotic medication." Which of the following statements is the most therapeutic response by the nurse?

"You are concerned that the client is receiving too much narcotic medication?" Explanation: Using a reflective statement without judgment allows the family to elaborate so the nurse can answer the specific concerns. The other options are not correct because they do not promote more conversation to help the family gain a better perspective on the treatment.

A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place.

0.7 Explanation: 10 mg : X = 15 mg : 1 mL 15 mg × X = 10 mg × 1 mL 15X = 10 mL X = 0.67 mL, which rounds to 0.7 mL.

A client receiving intravenous heparin has developed hematuria and petechiae. What is the nurse's best action?

Administer protamine sulfate Explanation: Heparin are pharmacotherapeutic agents for those with disorders such as coronary artery disease and other ischemic coronary events, atrial fibrillation, heart valve diseases, stroke, pulmonary embolism, and deep venous thrombosis. But there is a potential for many side effects with the use of this drug. Thrombocytopenia and bleeding events are the most common drug-related problems associated with heparin. Protamine sulfate is the heparin antidote. The administration of any of the other drugs will not aid in coagulation and resolve the bleeding.

A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse?

Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Explanation: It is important to explore the client's concerns regarding the side effects. As a follow-up, it is important to reinforce what is the desired effect of the drug. It is critical to explain the importance of not suddenly discontinuing its use. Explaining the symptoms of the disease does not identify the reasons for the client's concern. Encouraging the client to take the medication or documenting the refusal does not identify the concerns.

The nurse is evaluating a parent's understanding of measuring one tablespoon of medication in a medicine cup. At which level on the medicine cup would the nurse confirm an appropriate dose?

Explanation: One tablespoon equals 15 cc's of medication.

A nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?

Runs of ventricular tachycardia on a cardiac monitor Explanation: Physicians sometimes use lidocaine drips to treat clients whose arrhythmias haven't been controlled with oral medication and whose runs of ventricular tachycardia are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren't as significant as ventricular tachycardia in this situation.

A client with chronic obstructive pulmonary disease has a new prescription for theophylline. Which of the following information obtained from the client would prompt the nurse to consult with the healthcare provider?

The client takes cimetidine 150 mg daily. Explanation: Cimetidine interferes with the metabolism of theophylline and may cause theophylline toxicity. Theophylline should be taken as prescribed even if the client is not experiencing any symptoms of shortness of breath. An elevated heart rate is an expected side effect of theophylline and moderate exercise in a client with COPD. Thick mucus production is also an expected symptom of COPD.

The nurse is providing dietary instructions for a client who is taking warfarin. Which menu choice would be most appropriate for this client?

Tuna fish sandwich, French fries, and a baked apple Explanation: Vitamin K activates clotting factors and may interfere with the action of warfarin. Vitamin K is found in green leafy vegetables, broccoli, brussels sprouts, asparagus, blueberries, kiwis, grapes, blackberries, and plums and therefore these foods should be consumed in moderation.

Explanation: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.

a client who is beginning training for a tennis team Explanation: A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.

A loading dose of digoxin is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is:

a return demonstration of palpating the radial pulse. Explanation: The goal of the education program is to instruct the client to take the pulse; therefore, the expected outcome would be the ability to give a return demonstration of how to palpate the heart rate.

The nurse reviews the peak and trough serum levels from a client who is receiving gentamicin sulfate in order to:

adjust the dosage to the therapeutic range. Explanation: Peak and trough serum levels are used to adjust the dosage within a therapeutic range.

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug?

increased bowel movements Explanation: Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose.

When preparing the teaching plan for a client about lithium therapy, the nurse should teach the client about:

maintaining an adequate sodium intake. Explanation: The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels. Therefore, the drug may not reach therapeutic effectiveness.

An outpatient client who has been receiving haloperidol for two days develops muscular rigidity, altered consciousness, a temperature of 103° F (39.4° C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication?

neuroleptic malignant syndrome Explanation: The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening.

Cross-tolerance to a drug is defined as:

one drug reduces response to another drug. Explanation: Cross-tolerance occurs when a drug with a similar action causes a decreased response to another drug. A drug that can prevent withdrawal symptoms from another drug describes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. A drug's ability to increase the potency of another drug describes potentiating effects.

For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met?

pain rating of 0 on a scale of 0 to 10 by the client Explanation: If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/min is not within normal limits, nor is the PaO2 of 70 mm Hg (9.31 kPa), but these values are not measures of pain relief.

The nurse should ensure that which item is placed when the client is to receive intravascular therapy for more than 6 days?

peripherally inserted central catheter (PICC) Explanation: When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or peripherally inserted central catheter (PICC) is preferred to a short peripheral catheter. In adult clients, use of the femoral vein for central venous access should be avoided. Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.

An elderly client is receiving meperidine after abdominal surgery. The nurse should observe the client for which most significant side effect of meperidine?

respiratory depression Explanation: It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse effects of meperidine, but respiratory depression is most significant in the elderly.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

urine output greater than 30 ml/hour Explanation: Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

A client who is using a patient-controlled analgesia (PCA) pump after bowel surgery states, "I'm afraid that I'll become addicted if I use too much morphine." Which would be the best response by the nurse?

"When morphine is used to alleviate severe pain for 2 to 3 days, there is little likelihood of becoming addicted." Explanation: Morphine is a narcotic. Clients need to understand that when pain is present and morphine is used therapeutically, there is less likelihood of addiction. If morphine is taken in the absence of pain, addiction can result. Telling the client that morphine is not addicting is incorrect because, although it acknowledges the addictive nature of morphine, it does not inform the client regarding its effect in pain management. It is also nontherapeutic because it asks a "why" question. Asking about prior drug addiction is not appropriate at this time.

A physician orders an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, a client should receive how many milliliters of I.V. fluid per hour?

120 ml/hour Explanation: First, the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2,400 ml ÷ 2 = 1,200 ml. Then she determines how many of these milliliters to deliver per hour: 1,200 ml ÷ 10 hours = 120 ml/hour.

Because of a shortage of IV infusion pumps, a nurse must regulate a client's IV by gravity flow. The client has an order for 1000 mL of 0.9 NSS to infuse at 100 mL/hr. The tubing drip factor is 10 drops/mL. What is the appropriate rate for the nurse to set the IV infusion?

17 drops per minute Explanation: The accurate formula used to calculate drip rate of the IV is volume per hour, divided by infusion time in minutes, multiplied by the drip factor of the tubing. The other options are calculated incorrectly.

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360 Explanation: 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml

Guaifenesin 300 mg four times a day has been prescribed as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using one decimal place.

7.5 Explanation: Problems associated with long-term corticosteroid therapy include sodium retention, osteoporosis, and hyperglycemia. An increase in calcium and vitamin D is needed to help prevent bone deterioration. Dietary modifications need to reduce sodium, maintain high protein levels for tissue repair, and reduce carbohydrates, as there is a tendency toward hyperglycemia. Increased intake of complex carbohydrates is not indicated because of hyperglycemia. There should be decreased fat intake because there is a tendency for central fat deposition.

A nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site should the client use?

Anterior aspect of the thigh Explanation: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.

The nurse is reviewing the following physician's order written for a postmenopausal woman: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order?

Clarify with the physician that the spray should be given in only one nostril per day. Explanation: Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal women for the treatment of osteoporosis and requires a physician's order.

The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, what should the nurse do?

Consult the drug guide provided by the clinical agency. Explanation: The most current pharmacology information is found in the clinical agency's drug guide, that may be available on electronic sources that are frequently updated and can be transmitted to a handheld device or by logging into the internet or hospital's intranet, if available. A commercially published drug guide and pharmacology textbooks are outdated once published and, therefore, may not have current information. The manufacturer's website has the potential for bias.

A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client?

Continue to maintain normal sodium intake while at home. Explanation: Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased. Reduced sodium intake can lead to lithium toxicity. Nursing is not allowed to tell a client to adjust dosages of any drugs. A low-protein snack is not reflective or needed with this drug. Avoiding participation is not a therapeutic discussion.

A child has been prescribed a 3-day treatment of gentamicin sulfate. Which of the following manifestations would indicate that the child is developing toxicity?

Decreased renal output Explanation: Gentamicin sulfate is an antibiotic that can cause ototoxicity and nephrotoxicity. Therefore, a decrease in renal output would be concerning. Electrolyte and visual disturbances and joint discomfort would not be indicative of gentamicin toxicity.

A client with cancer of the stomach tells the nurse, "I cannot bear the pain anymore. Please give me some poison to free myself from this agonizing pain." The nurse faces a value conflict. Which of the following is true in such a condition?

Human need may affect the values conflict. Explanation: Human need may affect values conflict. Though the client is refusing further treatment, the nurse should be aware that the client needs the treatment. The nurse should not consider only the values of the client. When faced with a values conflict, nurses should examine their own values regarding the conflict. Value conflict may affect the client's compliance. Values conflict is not always destructive in nature. At times, it may even be constructive.

Which client statement indicates to the nurse that the client needs further teaching about disulfiram?

I can drink one or two beers and not get sick while on disulfiram." Explanation: Any amount of alcohol consumed while taking disulfiram can cause an alcohol-disulfiram reaction. The reaction experienced is in proportion to the amount of alcohol ingested. The alcohol-disulfiram reaction can begin 5 to 10 minutes after alcohol is ingested. Symptoms can be mild, as in flushing, throbbing in the head and neck, nausea, and diaphoresis. Other symptoms include vomiting, respiratory difficulty, hypotension, vertigo, syncope, and confusion. Severe reactions involve respiratory depression, convulsions, coma, and even death. Disulfiram can be taken at bedtime if the client feels sleepy from the medication. Some clients experience a metallic or garlic taste when initiating disulfiram treatment. Anything containing alcohol, such as cough medicine, aftershave lotion, and mouthwash, can cause a reaction. Therefore, the client needs to check the labels of these items for their alcohol content.

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?

Inspect the infusion site. Explanation: The nurse should first check the infusion site to be sure the site has not infiltrated. Next, the nurse should check the PCA pump to determine if it is functioning properly. Assessing vital signs would be important to provide additional data about the possible cause of pain, but is not the first action at this time. It is not necessary to notify the health care provider (HCP) unless the infusion site or pump is malfunctioning and other methods of managing the pain are required.

The physician has prescribed amiodarone for a client with cardiomyopathy. The nurse should monitor the client's rhythm to determine the effectiveness of the medication in controlling:

Life-threatening ventricular dysrhythmias. Explanation: Cardiomyopathy means that the myocardium is weak and irritable. Amiodarone is an antiarrhythmic and acts directly on the cardiac cell membrane. In this situation, amiodarone is used to increase the ventricular fibrillation threshold. Amiodarone is contraindicated in sinus node dysfunction, heart block, and severe bradycardia.

A client is scheduled for surgery at 8 a.m.(0800). While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation?

Notifying the surgeon that the client hasn't signed the consent form Explanation: Notifying the surgeon takes priority because the physician must obtain informed consent before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent to surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery isn't within the scope of nursing practice.

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse?

Slow the intravenous rate and notify the physician. Explanation: The increased volume from too-rapid fluid infusion will result in increased heart rate. There can be pulmonary edema with resultant increase in the respiratory rate to compensate. Jugular vein distension also indicates fluid overload. The rate of the intravenous fluids would need to be slowed, and the physician notified for new orders. Repeating the vital signs in 1 hour is incorrect because the client is already in distress. Lowering the head of the bed will increase the symptoms. Although oxygen may help, the priority is to decrease fluid volume.

A client begins taking haloperidol. After a few days, he experiences severe tonic contractures of muscles in his neck, mouth, and tongue. The nurse should recognize this as:

dystonia. Explanation: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. Mistaking the symptoms for psychotic symptoms can lead to misdiagnosis. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates:

evidence of a bleb or wheal. Explanation: A properly administered intradermal injection shows evidence of a bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.

If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to:

immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. Explanation: Reporting a noted discrepancy to the nurse-manager, nursing supervisor, and pharmacy should be the nurse's first step. Although the discrepancy may be easily corrected if investigated, the investigation isn't a nurse's responsibility. Documenting the discrepancy on an incident report or opioid-inventory form doesn't address the problem.

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. The nurse should tell the client to:

take the medication immediately. Explanation: The nurse should instruct the client to take the medication immediately or as soon as she remembers that she missed the medication. There is only a slight risk that the client will become pregnant when only one pill has been missed, so there is no need to use another form of contraception. However, if the client wishes to increase the chances of not getting pregnant, a condom can be used by the male partner. The client should not omit the missed pill and then restart the medication in the morning because there is a possibility that ovulation can occur, after which intercourse could result in pregnancy. Taking two pills is not necessary and also will result in putting the client off her schedule.

The nurse is instructing the client with hypothyroidism who takes levothyroxine 100 mcg, digoxin, and simvastatin. Teaching regarding the use of these medications is effective if the client will take:

the levothyroxine before breakfast and the other medications 4 hours later. Explanation: Levothyroxine) must be given at the same time each day on an empty stomach, preferably ½ to 1 hour before breakfast. Other medications may impair the action of levothyroxine absorption; the client should separate doses of other medications by 4 to 5 hours.

The nurse is administering 5,000 units heparin subcutaneously to a client (see the accompanying image). The nurse should:

use a shorter needle. Explanation: Heparin should be administered into subcutaneous tissue at a 90-degree angle using a 27-gauge 5/8-inch (1.6-cm) needle. The medication should not be administered into the muscle. In order to prevent hematoma formation, the nurse should not rotate the tip of the needle or aspirate before injecting the heparin.

A nurse has an order to administer iron dextran 50 mg I.M. injection. When carrying out this order, the nurse should:

use the Z-track technique. Explanation: Iron dextran is an iron preparation given using the Z-track technique to prevent leakage into the subcutaneous tissue and staining of the skin. When giving an I.M. injection using the Z-track technique, the nurse pulls the skin laterally away from the injection site to seal the drug in the muscle, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication to ensure drug dispersion, then simultaneously withdraws the needle and releases the skin to seal the needle track. Wiping the needle immediately after injection poses the risk of a needle stick.

The nurse is preparing a client for a cardiac catheterization. Which of the following client statements would the nurse need to report to the healthcare provider immediately?

"I took my metformin this morning." Explanation: The priority would be to notify the healthcare provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

When admitting a neonate whose mother received magnesium sulfate, the nurse should assess the baby for which complication? Select all that apply.

-decreased muscle tone - decreased respirations Explanation: Magnesium sulfate decreases muscle contractility and crosses the placenta. Because of this, a neonate that has been exposed to this drug may have decreased muscle tone and decreased respirations. The Moro reflex will be decreased because of the decreased muscle tone. There are no findings that show magnesium sulfate has a direct effect on temperature.

A client is receiving magnesium sulfate at 3 g/h intravenously. The bag of 1,000 mL normal saline contains 20 g of magnesium sulfate. How many mL/hour should the nurse set the IV pump rate in order to deliver 3 g/h? Record your answer using a whole number.

150 Explanation: The rate can be calculated as follows: mL/hr = (1000 mL/20 g) X (3 g/1 h) = (3000 mL/20 h) = 150 mL/h.

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?

Inspect the infusion site. Explanation: The nurse should first check the infusion site to be sure the site has not infiltrated. Next, the nurse should check the PCA pump to determine if it is functioning properly. Assessing vital signs would be important to provide additional data about the possible cause of pain, but is not the first action at this time. It is not necessary to notify the health care provider (HCP) unless the infusion site or pump is malfunctioning and other methods of managing the pain are required.

A nurse has been asked to insert peripheral IV lines in several clients on the nursing unit. Which of the following sites would the nurse need to avoid in order to maintain client safety?

The arm of a client where an arteriovenous shunt has been inserted Explanation: The nurse should avoid the arm with an arteriovenous shunt so the shunt is not jeopardized if the IV infiltrates, if the area becomes infected or inflamed, or if a thrombosis develops. The other options are incorrect because they could be used without risk to the client. It would be unsafe to use the affected side of a client who has had a mastectomy, but the unaffected side would be appropriate. The nurse should avoid broken or inflamed skin, but a sunburn without blisters could be considered.

The nurse is reviewing the laboratory report with the client's lithium level prior to administering the 1700 hours dose. The lithium level is 1.8 mEq/L (1.8 mmol/L). The nurse should:

hold the 1700 hours dose of lithium. Explanation: The nurse should hold the 1700 hour dose of lithium because a level of 1.8 mEq/L (1.8 mmol/L) can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination, which are early signs of lithium toxicity. The nurse should report the lithium level to the health care provider (HCP) , including any symptoms of toxicity. Administering the 1700 hour dose of lithium, giving the client the lithium with 240mL of water, or giving it after supper would result in an increase of the lithium level, thus increasing the risk of lithium toxicity.

The nurse is caring for a client with an IV line. During care of the IV line, the nurse would be required to wear protective gloves in which of the following situations? Select all that apply.

- When inserting the IV - When discontinuing the IV -When changing the IV site Explanation: The nurse should wear protective gloves when inserting the IV, when discontinuing the IV, and when changing the IV site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.

A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.

-"Take off the cap and shake the inhaler." -"Attach the spacer." -"Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." -"Press down on the inhaler once and breathe in slowly." -"Hold your breath for at least 10 seconds, then breathe in and out slowly." - "Rinse your mouth." Explanation: Using a spacer, especially with inhaled corticosteroid, can make it easier for the medication to reach the lungs; it can also prevent excess medication remaining in the mouth and throat, which can cause minor irritation. It is important for the client to empty the lungs, breathe in slowly, and hold the breath to draw as much medication into the lungs as possible. Rinsing after using a corticosteroid inhaler may help prevent irritation and infection; rinsing will also reduce the amount of drug swallowed and absorbed systemically.

A client who underwent surgery had the following intake on the day of surgery: Day shift: 500 mL packed blood cells; 236 mL platelets; 750 mL normal saline solution; 1 L dextrose 5% in normal saline solution Evening shift: 250 mL normal saline solution; 1 L dextrose 5% in normal saline solution Night shift: 1 L dextrose 5% in normal saline solution. How many milliliters of solution should the nurse document as the client's 24-hour intake? Record your answer using a whole number.

4736 Explanation: To determine the 24-hour intake, first convert items measured in liters to milliliters: 1 L dextrose 5% normal saline = 1,000 mL. Next, the nurse should add up the intake of all shifts. 500 mL of packed blood cells + 236 mL of platelets + 750 mL of normal saline solution + 1,000 mL (1 L) dextrose 5% in normal saline solution + 250 mL of normal saline solution + 1,000 mL (1 L) dextrose 5% in normal saline solution + 250 mL of normal saline solution + 1,000 mL (1 L) dextrose 5% in normal saline solution + 1,000 mL (1 L) dextrose 5% in normal saline solution = 4,736 mL.

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which of the following is the most important effect to report to the physician?

Palpitations and chest pain on exertion Explanation: Assessment of the effects of severe hypothyroidism on the circulatory system is important. Serum cholesterol levels are also elevated in clients with hypothyroidism. As the metabolic rate increases with the thyroid replacement therapy, there is more demand on the heart, and angina and palpitations may occur. All of the choices are expected effects once the replacement hormone is started. There is an increase in temperature, a loss in weight, and increased energy levels.

Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do?

Pull the auricle lobe up and back. Explanation: The nurse should have the client lie on the side opposite the affected ear. To straighten the client's ear canal, pull the auricle of the ear up and back for an adult. For an infant or a young child, gently pull the auricle down and back to the nasopharynx. The eardrops should be administered at body temperature.

A client is prescribed warfarin sodium. The nurse has prepared 1 tablet of 5 mg, 1 tablet of 2 mg, and 1/2 tablet of 3 mg. What is the dose that the nurse will be administering? Record your answer using one decimal place.

8.5 Explanation: Calculations must be done to ensure accuracy of the dosage. Results of the prothrombin times and INR will determine the amount of warfarin to be administered on a daily basis while in the hospital.

A physician prescribes intravenous heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction (MI). After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The healthcare provider orders the infusion to be increased to 800 units/hour. The nurse would set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number.

8 Explanation: The nurse would calculate the infusion rate using the following formula: Dose on hand/Quantity on hand = Dose desired/X 25,000 units/250 ml = 800 units/hour ÷ X 25,000 units x X = 250 ml x 800 units/hour 25,000 x X = 200,000 ml/hour X = 8 ml/hour

The nurse is admitting a client with glaucoma. The client brings prescribed eyedrops from home and insists on using them in the hospital. The nurse should:

explain to the client that the health care provider (HCP) will write a prescription for the eyedrops to be used at the hospital. Explanation: In order to prevent medication errors, clients may not use medications they bring from home; the HCP will prescribe the eyedrops as required. It is not safe to place the eyedrops in the client's medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eyedrops home.

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)?

Epoetin alfa 6500 U SQ daily. Explanation: The order written as "Epoetin alfa 6500 U SQ daily" is incorrect according to the Joint Commission's "do not use" list. "U" should not be used because it may be mistaken as zero (0), 4 (four), or cc. The healthcare professional should write "unit" instead. The other medication orders are written correctly. The order for diazepam does not include a trailing zero in the dosage. The order for levothyroxine sodium includes a leading zero prior to the dose. The acetaminophen order is correct in the use of the word "every" instead of Q.D., QD, q.d., or qd.

Long-term administration of gentamicin sulfate to a client has been discontinued. What should the nurse assess?

vestibular check in 3 to 4 weeks Explanation: Gentamicin is ototoxic; therefore, the client should have a vestibular and auditory check 3 to 4 weeks after discontinuing the drug. This is the most likely time for deafness to occur. It is not necessary to check the client's hemoglobin level, white blood cell count, or serum potassium level solely on the basis of having taken gentamicin. The blood urea nitrogen level and the creatinine level will be checked to assess renal function, if necessary.

A client is to be discharged with a prescription for lactulose. The nurse teaches the client and the client's spouse how to administer this medication. Which statement would indicate that the client has understood the information?

"I will mix it with apple juice." Explanation: The taste of lactulose is a problem for some clients. Mixing it with fruit juice, water, or milk can make it more palatable. Lactulose should not be given with antacids, which may inhibit its action. Lactulose should not be taken with a laxative because increased stooling is an adverse effect of the drug and would be potentiated by using a laxative. Lactulose comes in the form of syrup for oral or rectal administration.

A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply.

- Verify the medication order as written by the by the health care provider. (HCP). -Contact the pharmacy and speak to a pharmacist. -Request that cephalexin be sent promptly. -Return the cefazolin to the pharmacy. Explanation: One of the "five rights" of drug administration is "right medication." Cefazolin was not the medication prescribed. The pharmacist is the professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse.