Skills Study Set

The nurse is preparing to administer medications to a client with a gastric tube. What equipment will the nurse gather to administer medications to the client? Select all that apply. 1. Pill cutter 2. Waterproof pad 3. Tap water 4. Gloves 5. Irrigation set

2, 3, 4, 5 Rationale: To administer medications the equipment needed includes gloves, waterproof pad, irrigation set, and tap water. A pill cutter is not needed to administer medications to a client with a gastric tube.

The nurse cares for a client with a gastric tube in place. Which actions does the nurse perform? Select all that apply. 1. Insert a large syringe to decompress the stomach when the client reports nausea. 2. Administer one can of nutritional formula every 4 hours as prescribed. 3. Give liquid stool softener and crushed pain medication through the tube as needed. 4. Set the pump to deliver total parenteral nutrition (TPN) continuously at a low rate. 5. Deliver a dose of regular insulin through the tube with each meal time feeding.

1, 2, 3 Rationale: The gastric tube is used to remove stomach or intestinal secretions (decompression), deliver formula feedings to meet nutritional needs, and deliver liquid, powder, or crushed medications. The gastric tube is not used to deliver subcutaneous injections or intravenous fluids. The nurse is correct to use a syringe to decompress the stomach for reports of nausea; this action can prevent vomiting. The nurse administers liquid and crushable medications through the tube in addition to any enteral feeding prescribed. Regular insulin cannot be administered orally or gastrically; it is only subcutaneous and intravenous. Parenteral nutrition is intravenously delivered through an infusion pump into a central IV access.

The nurse splits a medication for client administration. What should the nurse do to assure safety and proper documentation? Select all that apply. 1. Take computer to the bedside. 2. Take medication to bedside. 3. Take medication package and label to bedside. 4. Take the client's entire medication drawer to bedside. 5. Take health care provider's prescription to the bedside.

1, 2, 3 Rationale: To assure safety and proper documentation of a medication administration, the medication, medication package and label, and computer should be taken to the client's bedside before administering medication. There is no need to take the health care provider's prescription or the client's entire medication drawer to the bedside.

The nurse is educating a family of a client with a gastric tube about administering medications. What would be appropriate to include? Select all that apply. 1. Delayed-response tablets cannot be ground. 2. All ground powder must be mixed with tap water. 3. Sterile water must be used in the gastrointestinal system. 4. Tablets must be ground to a fine powder. 5. Enteric-coated tablets cannot be ground.

1, 2, 4, 5 Rationale: Tablets must be ground into a fine powder and mixed with tap water. Enteric-coated and delayed-response tablets cannot be ground; if a medication has enteric coating or a delayed response, it was intended not to have an immediate response, so crushing the medication would not produce the delayed effect. Sterile water is not necessary when administering medications through the gastric tube.

The client with a gastric tube is prescribed a delayed-release tablet. Which are appropriate actions for the nurse? Select all that apply. 1. Check the drug guide. 2. Crush the timed-release medication. 3. Call the health care provider for prescription. 4. Split the medication. 5. Hold the medication.

1, 3, 5 Rationale: If a medication has a delayed-release response, it cannot be crushed or split. The medication is intended to have a delayed response and crushing it would not produce this effect; it would have an immediate effect instead. Holding the medication and calling the health care provider for additional prescription are also appropriate actions, as well as checking the drug guide to verify if the medication can be crushed or split.

The nurse is administering medications to the client. What does the nurse explain to the client who asks about the checks of medication administration? Select all that apply. 1. "I check the label when taking medication from the storage area." 2. "I check each label after pharmacy delivers medication to the storage area." 3. "I check the label of any medication before administering it to you." 4. "I check every label immediately after administering it to you." 5. "I check the label before removing the medication from its container."

1, 3, 5 Raionale: The nurse should check the label when he or she selects the container or unit dose package; after he or she takes it from the storage area and compares it with the medication administration record; and right before administering the medication to the client. There is no need to check the label after the pharmacy delivers the medication if the nurse is not going to administer it at that time. Labels should be checked before administering to the client.

Which are basic principles of surgical asepsis? Select all that apply. 1. Only a sterile object can touch another sterile object. 2. Forceps soaked in disinfectant can be used to add items to a sterile field. 3. Hold sterile objects at hip level or above. 4. Never turn the back on a sterile field. 5. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. 6. Avoid talking, coughing, sneezing, or reaching over a sterile field.

1,4,5,6 Rationale: Never walk away from or turn the back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Consider the outer 1-inch (2.5 centimeters) edge of a sterile field to be contaminated. Only a sterile object can touch another sterile object. Unsterile touching sterile means contamination has occurred. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Hold sterile objects above waist level. This will ensure keeping the object within sight and preventing accidental contamination. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile.

The nurse is preparing to administer medications to a client with a gastric tube. What information should the nurse check before administering any medication through the gastric tube? Select all that apply. 1. residual of stomach contents 2. whether tube feedings should be held 3. if medication should be given on full or empty stomach 4. client's allergies 5. placement of tube

2, 3, 4 Rationale: Before any medications should be administered the nurse should check for allergies, if the medication(s) should be administered on a full or empty stomach, and whether tube feeding should be held. Residual and placement of tube should be initiated immediately before administering medications.

When administering medications to a client, what information should the nurse know about the medication? Select all that apply. 1. cost 2. purpose 3. action 4. adverse effects 5. safe dose range

2, 3, 4, 5 Rationale: The nurse should know the following information about the medications being administered: its actions, special nursing considerations, safe dose ranges, allergies, purpose, and adverse effects. The nurse does not need to know the cost of the medication.

A nurse is distributing the 0900 medications to the client. What should the nurse do when removing a tablet from a multi-dose bottle? Select all that apply. 1. Touch the tablet(s) with the fingers. 2. Take the multi-dose bottle into the client's room. 3. Pick up two tablets directly from the bottle. 4. Put an extra tablet back into the bottle from cap. 5. Use gloves for extra protection.

2, 4, 5 Rationale: The nurse must refrain from touching the tablets. It is permitted to put an extra tablet back into the bottle if it was deposited into the cap first. It is permitted to take the multi-dose bottle into the room if the room is not isolation. It is permitted to use gloves in any situation when the nurse feels the need for extra protection.

The nurse needs half of a tablet of medication and is preparing to split the tablet but there is no score. What should the nurse do? Select all that apply. 1. Administer a whole tablet. 2. Check with the pharmacy. 3. Call the health care provider. 4. Refrain from splitting the tablet. 5. Cut the tablet in half.

3, 4 Rationale: The nurse should refrain from splitting the tablet because only scored tablets can be cut in half so that the client gets the correct dose. The health care provider should be called to relay that the medication cannot be given as prescribed and request another prescription. The nurse should not administer a whole tablet nor cut the tablet in half unless there is a score on the tablet.

The nurse is splitting medications. After splitting the tablet and administering half to the client, what should the nurse do with the remaining half? Select all that apply. 1. Dispose of medication in a toilet. 2. Send medication back to the pharmacy. 3. If the medication is a narcotic, waste with another nurse present. 4. Save medication in client's drawer for next administration. 5. Dispose of medication per hospital protocol.

3, 5 Rationale: Medications should already be split, if coming from the pharmacy. If the nurse uses unit stock and must split, the medication must be disposed of per hospital protocol. If the medication is a narcotic, the medication should be wasted in the presence of another nurse. Medications should not be wasted in the toilet or down a sink, sent back to pharmacy, or saved in the client's drawer.

The nurse is preparing to draw up a medication that is supplied in a glass ampule. Place in order, the steps the nurse will take. Use all options. 1. Withdraw the medication. 2. Attach a sterile administration device to the syringe. 3. Attach the filter needle to the syringe. 4. Discard the filter needle. 5. Wrap a small gauze pad around the neck of the ampule. 6. Break off the top of the ampule.

5, 6, 3, 1, 4, 2 Rationale: The correct order of steps for drawing up a medication that is supplied in a glass ampule is as follows: 1) Wrap a small gauze pad around the neck of the ampule. 2) Break off the top of the ampule. 3) Attach the filter needle to the syringe. 4) Withdraw the medication. 5) Discard the filter needle. 6) Attach a sterile administration device to the syringe.

The nurse is preparing to perform handwashing. Place the following steps in the correct order. Use all options. 1. Turn the faucet off with a paper towel. 2. Wash the palms and backs of the hands for at least 20 seconds. 3. Wet the hands and wrists. 4. Pat the hands dry with a paper towel. 5. Apply soap. 6. Turn on the faucet and adjust the force and temperature of the water.

6,3,5,2,4,1 Rationale: First, turn on the water and adjust force. Second, wet the hands and wrists. Third, use about 1 teaspoon of liquid soap from the dispenser or rinse a bar of soap and lather thoroughly. Fourth, with firm rubbing and circular motions, wash the palms and backs of the hands, each finger, the areas between the fingers, and the knuckles, wrists, and forearms. Continue this friction motion for at least 20 seconds. Fifth, pat the hands dry with a paper towel, beginning with the fingers and moving upward toward forearms, and discard it immediately. Sixth, use another clean towel to turn off the faucet.

Which includes practices used to render and keep objects and areas free from microorganisms? A. Surgical asepsis B. Clean technique C. Hand hygiene D. Medical asepsis

A Rationale: This statement describes surgical asepsis, or sterile technique. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Hand hygiene is a type of medical asepsis specific to the hands and includes hand washing and use of alcohol-based handrubs.

The nurse needs to place gauze from a wrapped item into the sterile field. Which action does the nurse take? A. Drop the item from 6 in (15 cm) above the sterile field. B. Lay the item in an open package on the 1-in (2.5-cm) border. C. Extend the sterile field by laying the open package beside it. D. Remove the gauze from the package with one sterile hand.

A. Rationale: Dropping the item from roughly 6 in (15 cm) above the surface prevents contamination of the field or dropping the item too close to the 1-in (2.5-cm), nonsterile border. Removing the gauze with one sterile hand risks contamination of that hand. It does not extend the sterile field to lay an unsterile package to the outside of the 1-in (2.5-cm) border.

The nurse is performing hand washing using soap and water after providing client care. The nurse has performed hand hygiene using soap and water. What action would the nurse take next? A. Dry the hands with a paper towel. B. Turn off the water at the faucet. C. Use an alcohol-based handrub. D. Apply an oil-free lotion to both hands.

A. Rationale: After rinsing the hands, the nurse would dry the hands using paper towels, wiping from the fingertips toward the forearms. Once dry, the nurse would then use another clean paper towel to turn off the water at the faucet to prevent clean hands from coming in contact with the soiled surface. The fingernails are cleaned before the hands are rinsed. The hands are dried using clean paper towel. An alcohol-based sanitizer or hospital-provided lotion can be used after handwashing and drying, if desired.

The nurse is preparing hydrochlorothiazide 50-mg tablet from unit stock. The health care provider orders 75 mg of hydrochlorothiazide PO for the client's hypertension. How many tablets of hydrochlorothiazide will the nurse administer to the client? A. 1.5 tablets B. 2 tablets C. 0.5 tablet D. 1 tablet

A. Rationale: Because the client only needs 50 mg of hydrochlorothiazide per day, the nurse would need to split one of the 50-mg tablets in half to obtain the correct dose, which is 1.5 tablets. Administering 0.5, 1, or 2 tablets would be either too much or too little medication for the client. 75 mg ÷ 50 mg/tablet = 1.5 tablets

The nursing instructor observes the nursing student removing sterile gloves. Which action indicates the need for further teaching? A. The student pulls the gloves off starting with the fingertips prior to removal. B. The student rolls gloves into each other during removal for disposal in the waste can. C. The student uses one gloved hand to grab the outside surface of the other glove. D. The student reaches under the glove on one hand to peel the glove off of the other hand.

A. Rationale: Grabbing the outside surface of the non-dominant glove with the glove on the dominant hand ensures the gloves are removed smoothly without contaminating the room, surfaces, or the nurse's hands. The nurse ensures that the dirty side of the glove does not touch the skin and that any contaminants are contained to the glove's outer surface. The other actions are correct. The student does use one gloved hand to grab the outside surface of the other, reaches under the glove on one hand to peel the glove off the other hand, and rolls gloves into each other during removal for disposal in the waste can.

The nurse prepares for a sterile procedure. What action does the nurse perform first? A. Perform hand hygiene with alcohol-based handrub. B. Put on personal protective equipment, if required. C. Identify the client the procedure is prescribed for. D. Place all the necessary supplies in the room.

A. Rationale: Hand hygiene is done prior to donning any personal protective equipment, before entering the room, and before interacting directly with the client, such as checking the name on the armband.

The nurse is administering a client's medication and more tablets than needed fall into the bottle cap. What should the nurse do? A. Drop extra tablets into bottle from bottle cap. B. Drop the extra tablets down the sink. C. Throw the extra tablets away. D. Put the extra tablets into a specialty disposal unit.

A. Rationale: If more tablets than are needed fall into the bottle cap, the nurse should drop the extra tablets into the bottle from the bottle cap. The extra tablets should not be thrown away, dropped down the sink, or put into a specialty disposal unit.

The nurse is donning a pair of sterile gloves. The nurse correctly dons the first glove, but inadvertently inserts the thumb and index finger into the thumb hole of the second glove. The glove remains intact. Which action is most appropriate? A. Continue to don the glove, then use the other gloved hand to carefully insert the finger into the proper hole. B. Don a second pair of sterile gloves over the first pair. C. Use only the correctly gloved hand to perform the sterile procedure while making sure the other hand does not contaminate the sterile field. D. Leave both the thumb and finger in the thumb hole and perform the procedure to the best of the nurse's ability.

A. Rationale: It is appropriate to adjust the gloves as long as the nurse only touches sterile surface to sterile surface. Leaving the thumb and finger in the thumb hole or only using the correctly gloved hand to perform the sterile procedure would not be appropriate, nor would donning a second pair of gloves, in this case.

The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as needed dose, and the tablets in the container are not scored. What action by the nurse is best? A. Call the pharmacy to request a supply change. B. Cut the second tablet in half using a pill splitter. C. Administer one tablet until the issue is resolved. D. Document the medication dose as not administered

A. Rationale: The best action by the nurse is to request scored tablets or the correct dose from the pharmacy. If this is not possible, the nurse considers cutting the unscored tablet with the pill splitter, recognizing that this could result in an inaccurate dose. The nurse could choose not to give the medication, but this leaves the client in needless pain. The nurse could choose to administer two thirds of the dose by giving one tablet, but this leaves the client underdosed for pain relief.

The nurse uses a small amount of sterile solution from a large, multiuse bottle to moisten gauze in a sterile field. What technique does the nurse use? A. Pour the liquid into a sterile container within the sterile field. B. Pour the liquid onto gauze on the sterile field until the gauze is moist. C. Pour the liquid into the palm of a sterilely gloved hand for use. D. Pour the liquid into the cap of the bottle and dip the gauze as needed.

A. Rationale: The liquid from a large container is poured into a sterile container present within the sterile field. The gauze is placed in this container if needed or moistened as desired for use. If gauze is laying on the field and the field become moist, it may be considered contaminated.

The nurse is to administer a medication to a client in isolation and the medication is in a multi-dose container. How will the nurse complete the third check of medication administration? A. Check the multi-dose label before putting the container back in the drawer and label medicine cup with needed information. B. Check the multi-dose label before going into the room and leave the container outside the room. C. Complete the third check before placing the multi-dose container back in the drawer. D. Take the multi-dose container into the client's room and complete the third check in the room

A. Rationale: The multi-dose container should not be taken into an isolation room. The label should be verified, and medication placed into a medicine cup. The cup should be labeled with client's name, date of birth, identification number, medication name, and dose.

The nurse gathers supplies, including an extra pair of sterile gloves, for a sterile dressing change on a client's large abdominal wound. The nurse uses the extra gloves for what purpose? A. use if the first pair of sterile gloves gets contaminated B. To be able to change gloves if the wound has copious draining C. To leave in the room with additional supplies for the next change D. To remove the existing dressing from the abdominal wound

A. Rationale: The nurse brings in extra sterile gloves in case the first pair is contaminated by touching a non-sterile surface. It is always better to plan that this might occur. The existing dressing is removed with clean gloves and is considered dirty. Any drainage should be on the dressing when it is removed. Handled according to the nurse's discretion but drainage does not usually indicate the nurse needs to change gloves. The gloves can be left for the next dressing change, but this is not the purpose of bringing them into the room.

The nurse is preparing a liquid medication for a client. The health care provider prescribes cimetidine hydrochloride 600 mg PO for gastrointestinal bleeding. The pharmacy sends cimetidine hydrochloride 300 mg/5 mL. How many teaspoons should the nurse administer? A. 2 teaspoons B. 1.5 teaspoon C. 1 teaspoon D. 0.5 teaspoon

A. Rationale: The nurse should administer 2 teaspoons of the cimetidine hydrochloride. If the nurse administers 0.5, 1, or 1.5 teaspoons of the medication, the client will not receive the prescribed dose. The pharmacy sent medication with the concentration of 300 mg per teaspoon (1 teaspoon = 5 mL). and the dose is 600 mg. Therefore, to obtain a 600-mg dose, the nurse administers 2 teaspoons, or 10 mL.

When opening a pre-packaged kit to prepare a sterile field, which would be important to keep in mind? A. The inner surface of the outer wrapper is considered sterile. B. The edges of the wrapper are positioned to hang below the edges of the work surface. C. The outside surface of the outer wrapper becomes the sterile field. D. The outer 2-in (5-cm) border of the wrapper is considered contaminated.

A. Rationale: The outer wrapper of a pre-packaged kit is used to create the sterile field, such that the inner surface of the wrapper, which is sterile, becomes the sterile field once it is opened. The outside surface of the outer wrapper is considered contaminated. A 1-in (2.5-cm) border of the wrapper is considered contaminated. The wrapper is positioned on the work surface so that when it is flat, the edges are on the work surface and do not hang over the sides of the surface.

The nurse is preparing to administer medications to the client. The client sees the nurse double checking each medication and asks the nurse what is occurring. What is the nurse's best response? A. "Checking the medication again to ensure the right medication is given to you." B. "Checking the medication to make sure the health care provider prescribed the right medication." C. "Checking the bottles and packages to make sure the medication is not expired." D. "Checking to make sure the pharmacist sent the right medications for your needs."

A. Rationale: The purpose of checking the medication is to ensure that the right medication is going to the right client. Three checks are completed during medication preparation and administration. The nurse checks that the pharmacist sent the medication prescribed, but the pharmacist does not prescribe according to the client's needs. Though the nurse is responsible for ensuring the provider does not request a harmful medication or dose to be administered, it is not in the nurse's scope of practice to ensure the provider prescribed the correct medication. Though the package should be checked for an expiration date, this is not part of the triple-checking process, which is aimed at ensuring the correct medication is given the correct client at the correct time.

An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection? A. Health care-associated infection B. Sexually transmitted infection C. Respiratory infection D. Droplet infection

A. Rationale: This infection is best described as a health care-associated infection. A health care-associated infection is an infection not present on admission to health care agency and that has been acquired during the course of treatment for other conditions. The other terms listed do not apply to this infection.

The nurse is in the client's room to administer the client's morning oral medications. Which action should the nurse take first? A. Confirm the client's identity. B. Document the medications being given. C. Pour a cup of water for the client to drink. D. Open the unit-dose packages of medications.

A. Rationale: When administering medications to the client, first the nurse must confirm the client's identity to ensure that it is the "right client." Then the nurse would perform any assessments necessary for the medications being given. Next the nurse would open the medications and offer them to the client along with a fluid to drink. Documentation occurs after the medication has been given and the nurse has witnessed the client swallowing them.

The instructor observes a nursing student who is preparing a liquid medication from a multi-dose bottle. Which action would concern the instructor if it were demonstrated by the student? A. Holds the bottle of liquid medication with the label facing the medication cup. B. Wipes the lip of the container with a paper towel after pouring the liquid. C. Compares the label on the bottle with the medication administration record. D. Measures the liquid in the cup using the bottom of the meniscus at eye level.

A. Rationale: When pouring liquid medications, the bottle should be held with the label facing the palm of the hand to prevent any liquid from dripping onto the label while pouring and thus making it difficult to read. It is appropriate to wipe the lip of the container with a paper towel to prevent the liquid from dripping on the label. In addition, it is appropriate to measure the amount using the bottom of the meniscus and to compare the label on the bottle with the medication administration record.

The nurse is administering medications to a client via a gastric tube. After administering the last dose of medication, how much water should the nurse flush through the gastric tube? A. 15 to 25 mL B. 30 to 60 mL C. 65 to 75 mL D. 5 to 15 mL

B. Rationale: When administering medications via a gastric tube, the nurse would flush the tube with 30 to 60 mL of water to maintain tube patency. A 5- to 10-mL water flush would be used between medications when the nurse is administering more than one medication at a time. A 15- to 25-mL or a 65- to 75-mL water flush would be inaccurate amounts for the task.

A nurse is measuring a liquid medication in a graduated liquid medication cup. The nurse determines the correct amount by reading: A. on both sides of the amount line. B. the bottom of the meniscus. C. the top of the amount line on the cup. D. just below the line for the amount.

B. Rationale: When measuring the correct amount of liquid medication in a graduated liquid medication cup, the nurse would measure the liquid at eye level at the bottom of the meniscus to ensure an accurate dosage. Measuring at the top of the amount line, just below it or on both sides would be inaccurate.

The nurse prepares the sterile tray for indwelling catheter insertion while wearing sterile gloves. The nurse then pulls the client's blankets away from the pelvis to begin catheter insertion. What action should the nurse take next? A. Position the catheter kit closer to the client. B. Change into a new pair of sterile gloves. C. Begin cleansing the meatus with antiseptic. D. Dispose of the catheter kit and begin again.

B. Rationale: The client must be prepared prior to preparing the catheter kit. The nurse must wear sterile gloves while preparing the sterile tray, because it involves opening sterile supplies. If the nurse then touches a non-sterile surface, like the client's blankets, the sterile gloves must be changed prior to continuing the procedure. The nurse does not need to reposition the kit at this time. The nurse is no longer sterile and cannot proceed with cleaning the client with sterile solution. Only the nurse's gloves are contaminated; the nurse does not need to dispose of the kit.

A group of nurses are reviewing information about asepsis. Which statement by the group demonstrates the need for additional review? A. "Items below waist level are considered contaminated." B. "Turning a back to a sterile field maintains the sterility of the field." C. "Any items coming into contact with a sterile field must be sterile." D. "Reaching over a sterile field contaminates the sterile field."

B. Rationale: A sterile field becomes contaminated if the nurse turns his or her back to it. Any item that comes into contact with a sterile field must be sterile. Reaching over a sterile field contaminates the sterile field. Any items below waist level are considered contaminated.

A nurse is preparing a sterile field using a pre-packaged kit. The nurse opens the outside cover and removes the kit, placing it in the center of the work surface. The nurse places the kit so that the topmost flap is positioned in which direction? A. Toward the nurse's body B. On the far side of the package C. To the right of the client D. To the left of the nurse

B. Rationale: After the nurse opens the outside cover of the package and removes the kit, the nurse places it in the center of the work surface with the topmost flap positioned on the far side of the package. Doing so allows sufficient room for the sterile field. Then the nurse would reach around the package and grasp the outer surface of the end of the topmost flap, holding no more than 1 in (2.5 cm) from the border of the flap. This flap is then pulled open away from the body.

A nurse is preparing to administer oral medications to a client. While opening the unit dose package, the medication inadvertently falls on the floor. Which action by the nurse would be most appropriate? A. Notify the health care provider that the medication was dropped. B. Discard the current unit-dose package and obtain a new one. C. Document that the client refused the medication. D. Call the pharmacy to determine if the medication can be given.

B. Rationale: If a medication falls on the floor, the nurse must discard it and obtain a new dose. Since the medication was in a unit dose-package, the nurse would easily be able to tell which medication had fallen. The client did not refuse the medication so it would be inappropriate to document it as such. There is no need to call the pharmacy or notify the health care provider. The nurse would call the pharmacy if he or she was unsure as to which medication had fallen on the floor.

Which statement best explains the rationale for bringing an extra pair of sterile gloves into an adult client's room before preparing for a sterile procedure? A. Unfamiliar supplies and equipment may frighten the client, so demonstrating the use of sterile gloves before the procedure may make the client more compliant. B. If the first pair is contaminated and needs to be replaced, the nurse does not need to leave the room for a new pair. C. If another staff member enters the room and volunteers to assist, sterile gloves are immediately available. D. An additional pair will be needed if the client reveals a previously undisclosed sexually transmitted infection.

B. Rationale: It is a good idea to bring an extra pair of gloves when gathering supplies, according to facility policy. That way, if the first pair is contaminated in some way and needs to be replaced, the nurse will not have to leave the procedure to get a new pair. None of the other answers is as good of a rationale for bringing an extra pair of gloves into a procedure.

The nurse is caring for a client who has a newly written prescription for "fluoxetine 20 mg by mouth daily for treatment of depression." The nurse is unfamiliar with this medication. Which action is most appropriate? A. Ask a more experienced colleague about the medication. B. Inform the health care provider about being uncomfortable administering the medication. C. Consult a professional medication reference before preparing to administer the medication. D. Trust that the health care provider practices safely and administer the medication as prescribed.

B. Rationale: The nurse must not administer medications that are unfamiliar to him or her. The nurse should be able to review appropriate references, as opposed to consulting a colleague.

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication? A. Place the dose in the medication cup with other medications. B. Set the antihypertensive dose aside pending assessment. C. Teach the client to use the call bell whenever getting out of bed. D. Ask the client to report any dizziness and lightheadedness.

B. Rationale: Knowing that the previous dose was held, the nurse sets the antihypertensive aside until an assessment of current blood pressure is performed or verified. The nurse scans and administers all the regularly scheduled medications at one time, except for those requiring additional assessment. Those unit-dose packages are set to the side until the nurse is sure that administration is the correct action. The client should already know to call for assistance, if needed, and to report new or worsening symptoms, such as feeling dizzy.

The client overhears the nurse reviewing the rights of medication administration and asks, "Why are you saying, 'right medication, right client, right route, right dose'?" What is the nurse's best response? A. "Reciting these rights helps me avoid an error when giving medications." B. "I review these to make sure your medications are accurate and correct." C. "This is something that management insists that we do to reduce incidents." D. "I say those words repeatedly to ensure I have everything that is needed."

B. Rationale: Medication errors can be prevented by carefully adhering to these rights, understanding the important concepts that apply to each right, and utilizing a nursing drug reference guide to provide accurate information for each medication administered. Though it is partially correct, the nurse's goal is not to ensure that everything needed is in hand. Management does want the nurses to provide safe care and repeating the rights is one way to prevent errors; however, saying this to the client in these words introduces the idea that an error is very likely. The nurse does not want to cause the client to feel insecure about the care being provided.

What will the nurse do with the filter needle after withdrawing medication from an ampule? A. Remove the needle and save it for later administration of the medication. B. Remove the filter needle and attach the administration needle. C. Use the needle to inject air into the medication. D. Use the needle to administer the medication to the client.

B. Rationale: Once the medication is in the syringe, the nurse would remove the filter needle from the syringe and attach a new administration needle. To prevent glass shards from contaminating the medication, this needle is not used to administer the medication or inject air into the medication. Filter needles are not used to administer medications to clients as the glass shards would cause injury. Filter needles should be discarded, not saved for later use.

The nurse has created a sterile field with sterile dressings in preparation for a client's wound care. While getting ready to apply a dressing, the client moves his arm and touches the sterile field. Which action by the nurse would be most appropriate? A. Replace any items that moved with new ones. B. Set up an entirely new sterile field. C. Add new sterile dressings to the sterile field. D. Ask the client if he touched anything.

B. Rationale: The client came in contact with the sterile field. As a result, the sterile field is contaminated, and an entirely new sterile field must be created. Adding new sterile dressings to the sterile field would contaminate the new dressings because the sterile field is now contaminated. All the items need to be replaced. Asking the client if he touched anything would be inappropriate because the client's contact with the sterile field rendered it unsterile and it should not be used.

The nurse is educating a preoperative client about gastric tubes. The client asks, "Why do I need to have a gastric tube?" How should the nurse respond? A. "Your health care provider prescribed it for you." B. "To help you consume sufficient nutrition." C. "Only so you can get the medications you need." D. "Your stomach isn't working, and this will help."

B. Rationale: The gastric tube is usually placed for the client who cannot swallow or those who have had oral surgery to supplement feeding and allow the client to consume sufficient nutrition. Although the client will receive medications and the health care provider did prescribe placement of the gastric tube, the nurse must give clear and precise information to the client. In the client with a gastric tube the stomach is working, but the client may not be able to masticate or swallow.

The nurse is administering routine medications to a postsurgical client and the client asks, "Could I have something for pain?" The nurse checks the medication administration record (MAR) and notes that the medication is an opioid. What should the nurse do? A. Give all the medications together. B. Place the opioid into a separate cup. C. Administer the medication and let the client take it when the client wants. D. Open the pill into the client's hand.

B. Rationale: The medication should be given in separate cups so that an additional assessment can be performed. Orally administered medications should be dispensed into a medicine cup and ingested when administered, not when the client wants. Medications that need additional assessments should not be administered together.

The nurse administers medication to a client. Which statement by the nurse is required to satisfy the three checks and rights of medication administration? A. "Tell me if you have any swallowing difficulties." B. "Please tell me your name and date of birth." C. "You are taking 40 mg of pantoprazole here." D. "I have your lisinopril here for you to take."

B. Rationale: The minimum number of times the nurse should check the medication label before administering the medication is three times: right medication, right client, right route, right dose. Telling the client what the name and does of the medication is important, but this action does not help the nurse directly verify that these match what is prescribed. It is important to ensure the client can swallow if oral medications are prescribed, but this does not satisfy the required checks. The nurse verifies each medication, route, and dose is for the client when the medication is obtained, prepared, and administered. The initial checks are performed against the medication administration record, and the final check is done with the client's verbal participation and while visualizing the client's armband information.

When adding sterile items to a sterile field, the nurse would drop the sterile items from which height? A. 2 in (5 cm) B. 6 in (15 cm) C. 14 in (35 cm) D. 10 in (25 cm)

B. Rationale: When adding sterile items to a sterile field, the item is dropped from a height of 6 in (15 cm).

The nurse is performing the third medication check for a medication administered from a multi-dose bottle. What should the nurse do? A. Take the tablet out of the bottle and identify it visually. B. Check the multi-dose bottle label after identifying the client and before administering the medication. C. Check the client's identification after administration of the medication. D. Compare the medication label on the bottle to the medication administration record (MAR).

B. Rationale: When performing the third medication check for a medication from a multi-dose bottle, the nurse should check the multi-dose bottle label after identifying the client and before administering the medication. The tablet is not taken from the bottle and identified visually. Identification of the client is always performed before administration of the medication. The first, not third, medication check is to compare the medication label on the bottle to the MAR.

A nurse is preparing several oral medications for administration. One of the medications requires the nurse to obtain the client's apical pulse before administering it. Which action would be most appropriate? A. Giving the medication requiring the assessment at a different time. B. Placing the medication requiring the assessment in a separate medication cup. C. Putting all the medications to be given in the same cup. D. Completing the assessment before preparing the medication in the medication cup.

B. Rationale: When preparing several oral medications, including one that requires an assessment before administration, the nurse would place the medication in a separate medication cup so that it is easily identified should the assessment reveal the need to withhold the drug. Placing all the medications in the same cup could lead to confusion should the medication requiring assessment need to be held. Medications are prescribed to be given at specific times, so it would be inappropriate to give the medication at a different time from that which is prescribed. The nurse should have all the medications prepared before going into the client's room and performing the necessary assessments. Performing the assessment first and then going to prepare the medication would be less efficient.

When putting on the second sterile glove, the nurse places the gloved thumb at which location? A. Close to the palm of the gloved hand B. Outward away from the gloved hand C. Under the fingers, as in a fist D. Adjacent to the fifth finger

B. Rationale: When putting on the second sterile glove, the nurse holds the gloved thumb outward away from the rest of the gloved hand. The remaining gloved four fingers are placed inside the cuff of the second glove to apply it to the ungloved hand. The other grasping positions are awkward and not attempted

When removing soiled gloves, which action should the nurse take? A. Grab the gloved dominant hand at the wrist using the fingers of the non-dominant hand to invert the glove. B. Using the gloved dominant hand, grasp the glove of the non-dominant hand near the cuff on the outside. C. Slide the fingers of the gloved non-dominant hand between the skin and glove of the dominant hand. D. Pull on the fingertips of the gloved non-dominant hand using the fingers of the gloved dominant hand.

B. Rationale: When removing soiled gloves, the nurse would use the gloved dominant hand to grasp the opposite (non-dominant) glove near the cuff end on the outside and remove it by pulling it off while inverting it so that the contaminated area remains on the inside. The nurse would then slide the fingers of the now ungloved hand between the remaining glove and the wrist, pulling it off while inverting it, to keep the contaminated area on the inside and secure the first glove inside the second.

When preparing a sterile field, which action would be appropriate for the nurse to take first? A. Put on sterile gloves. B. Check the packages for expiration date. C. Open any sterile items to be used. D. Place the work surface at chest height.

B. Rationale: When setting up a sterile field, it is essential that the nurse check the packages for their expiration dates to ensure that the items are sterile. This must be done before opening any sterile items. The work surface should be placed at waist level before checking the expiration dates and opening any sterile packages. Sterile gloves are put on once the sterile field is set up.

The nurse opens the package of sterile gloves using the interior side folds, and the package will not open fully for the nurse to reach the gloves. What action does the nurse take? A. Slide the gloves out of the package. B. Open the top and bottom folds completely. C. Reach under the package folds to open. D. Obtain a new pair of sterile gloves.

B. Rationale: When the inside folds of the glove package will not open correctly, the nurse might not have fully opened the top and bottom folds of the package. When this occurs, the package keeps closing back in on itself, making it difficult to put the sterile gloves on correctly. Therefore, opening the bottom and top fold completely allows the interior side folds to open as needed. Sliding the gloves out of the package leads to the gloves contacting the edge of the sterile package, which is not considered sterile—just like any sterile field edge. Reaching under the package is not a useful action, and there is no reason to obtain new gloves yet.

The nurse uses soap and water for hand hygiene. Which action demonstrates proper handwashing? A. Drying the hands, then fingers B. Using a rubbing, circular motion C. Keeping the hands above the elbows D. Washing to 1 in (2.5 cm) below the elbows

B. Rationale: When washing the hands with soap and water, the nurse would use a rubbing circular motion to wash the palms and back of the hands, each finger, the areas between the fingers and knuckles, and the wrists and forearms. Throughout the process, the nurse would keep the hands lower than the elbows to allow water to flow toward the fingertips. The nurse would wash to at least 1 in (2.5 cm) above the level of contamination or to 1 in (2.5 cm) above the wrists. When drying the hands, the fingers are dried first and the nurse then moves upward toward the forearms.

The nurse has put on one sterile glove and is preparing to put on the other. What is the next step in donning the second glove? A. Use the thumb and index finger to grasp the cuff. B. Use the fingers to grasp the edges of the cuff of the second glove. C. Slide the gloved fingers under the cuff of the second glove. D. Hold the second glove in the palm of the gloved hand.

C. Rationale: After putting on the first glove, the nurse would slide the fingers of the gloved hand under the cuff of the second glove, thereby maintaining sterility, and insert the hand into the glove. When putting on the first glove, the nurse would use the thumb and index finger to grasp its cuff. Holding the second glove in the palm of the gloved hand would be inappropriate. Using the fingers to grasp the edges of the cuff of the second hand could cause contamination of the first gloved hand.

A group of students are demonstrating the skill for hand washing. What would indicate a need for additional teaching? A. The students rub their hands firmly with soap using a circular motion. B. The students use warm water to complete the hand washing skill. C. The students wash their hands for 15 seconds prior to drying them. D. The students keep their hands lower than their elbows throughout the skill.

C. Rationale: Hand washing is done for about 20 seconds, followed by a focus on the fingernails prior to rinsing off the soap. When performing hand washing, the water temperature should be warm to the touch. The hands should be kept lower than the elbows at all times to allow water to flow to the fingertips. Firm rubbing and a circular motion promotes friction that helps to loosen dirt and organisms that can lodge between the fingers, in skin crevices of the knuckles, on the palms and backs of the hands, and on the wrists and forearms.

While performing a sterile dressing change, the nurse inadvertently contaminates the right-hand glove. Which action by the nurse would be most appropriate? A. Cover the contaminated glove with a non-sterile disposable glove B. Continue the procedure using only the left gloved hand. C. Replace the current gloves with a new set of sterile gloves. D. Apply a new pair of sterile gloves over the current ones.

C. Rationale: If gloves become contaminated at any time, the nurse should remove the gloves and put on a new pair of sterile gloves. Using only the left hand, applying a new pair of gloves over the current pair, or covering the contaminated glove with a non-sterile one would be inappropriate.

What action does the nurse perform to remove gloves after performing a sterile procedure? A. Lay the first removed glove in the sterile field. B. Pull the glove off starting at the fingers. C. Invert the glove as it is removed. D. Place the first removed glove in the waste.

C. Rationale: Inverting the glove as it is removed is correct. This action decreases contamination risk during removal. Pulling the gloves off from the fingertips is a less clean manner in which to dispose of the gloves and can lead to contamination to the nurse. Gloves are not laid into the sterile field, but directly disposed of. The nurse disposes of the gloves together, not one at a time.

The nurse is preparing to administer a sublingual medication. Which instruction to the client is correct? A. "Swallow frequently to get the best benefit." B. "Take a big drink of water and swallow the pill." C. "Try not to swallow while the pill dissolves." D. "Chew the pill so it will dissolve faster."

C. Rationale: Place medications intended for sublingual absorption under the client's tongue. Instruct the client to allow the medication to dissolve completely. Reinforce the importance of not swallowing the medication tablet, as sublingual medications are intended to be absorbed through the oral mucosa.

While removing gloves after performing client care, what action does the nurse take? A. Wrap the discarded gloves inside the sterile field for waste disposal. B. Use hand sanitizer on the surface of the gloves prior to glove removal. C. Ensure the skin of the hands does not touch the outside surface of the glove. D. Discard each glove separately into the waste receptacle.

C. Rationale: The glove surface is contaminated, and one of the goals of wearing gloves is decreasing contamination between client and nurse. The nurse does not touch the outer surface of the glove with bare skin. Using hand sanitizer on the glove is a needless and unhelpful step. The gloves and sterile field remnants can be disposed of separately. Optimally, the gloves need to be folded into each other for disposal to decrease contamination risk.

The nurse is caring for a client with a gastrointestinal bleed who has a nasogastric (NG) tube. After administering the medications via the NG tube, what would the nurse do next? A. Flush with 30 mL hot water after the last medication. B. Reestablish nasogastric tube to low-intermittent wall suction. C. Shut off nasogastric tube for 30 minutes. D. Flush with 5 mL cold water after each medication.

C. Rationale: The nasogastric tube should be shut off for 30 minutes to enhance medication absorption and then reestablish decompression. The nasogastric tube should be reestablished to suction per the health care provider's prescription. The nasogastric tube should be flushed with 5 to 10 mL warm water after each medication, and 30 to 60 mL warm water after the last dose of medication.

When washing the hands with soap and water what is an appropriate action for the nurse to perform? A. Lean as close to the sink as possible. B. Remove jewelry prior to turning on water. C. Keep the hands below the elbows. D. Rub each hand with soap individually.

C. Rationale: The nurse keeps the hands lower than the elbows to allow water to flow toward fingertips. When hand washing, the nurse washes jewelry, usually restricted to only a wedding band, before starting; jewelry can harbor microorganisms and contaminants. Next, the nurse would turn on the water, apply soap to the hands, and rub it in using a circular motion. After thoroughly cleaning the hands, the nurse would then clean under the nails. The nurse does not lean on the sink as this can lead to contamination.

The nurse prepares the client's nightly medication doses and needs to administer an as needed dose of a hypnotic medication for sleep. The sleep medication is in a unit-dose package. What action does the nurse take? A. Place the medication in the cup with the scheduled night medications. B. Document the client's pain scale score between 0 and 10. C. Open the package after the client confirms the dose is wanted. D. Assess the client's blood pressure before administering the dose.

C. Rationale: This medication requires additional assessment prior to administration. The nurse needs to ensure the client still wants the sleep medication prior to opening it. The nurse does not need vital signs or the client's pain score to administer the sleep medication. The nurse does not place the medication with the scheduled medications.

The nurse enters the client's room to administer oral medications. Which action would the nurse take first? A. Confirm the client's identity. B. Ask the client about any allergies. C. Perform hand hygiene. D. Offer the client something to drink.

C. Rationale: When administering medications, the first step is to perform hand hygiene. The nurse then would confirm the client's identity and offer water or some other permitted fluids to take with the medications. The nurse would check the client's chart for any allergies, as well as ask the client prior to administering the medications if he or she has any allergies

The nurse is required to give a prescribed medication via a gastric tube. The medication is available in tablet form. What should the nurse do first? A. Use the tablet "as is," making sure to flush the tube after administration. B. Split the tablet into two halves for administration. C. Check the drug administration guide to see if the medication can be crushed. D. Mix the crushed tablet with a small amount of normal saline.

C. Rationale: When giving medications via a gastric tube, the medication should be in liquid form to prevent the tube from clogging. The nurse would first check the drug reference guide to see if the tablet can be crushed. If it can, the nurse would then crush the tablet and mix it with 15 to 30 mL of water or the recommended liquid. Splitting the tablet in half or using it "as is" would be inappropriate because the tablet would still be in solid form.

When pouring a liquid medication into a graduated liquid medication cup, which nursing action would be most appropriate? A. Hold the cup in the nondominant hand above waist level. B. Position the cup at an angle to the mouth of the liquid. C. Place the cup on a flat surface at eye level. D. Hold the cup directly against the lip of the liquid container.

C. Rationale: When pouring liquid medications, it is essential to place the cup on a flat surface at eye level and pour the liquid into the cup, reading the amount at the bottom of the meniscus. This ensures that the medication dosage is accurate. Pouring the liquid into a cup that is being held can lead to inaccurate dosages.

The client is to receive several medications via a gastric tube. How much water would the nurse flush the tube between the medications? A. 35 to 40 mL B. 25 to 30 mL C. 5 to 10 mL D. 15 to 20 mL

C. Rationale: When several medications are being administered via a gastric tube, the nurse would flush the tube with 5 to 10 mL of water after giving each medication. After the last dose of medication, the nurse would flush the tube with 30 to 60 mL to maintain tube patency.

The nurse is planning to use a pre-packaged kit to prepare a sterile field. Which would be of least importance in ensuring the sterility of the kit? A. The expiration date is not yet reached. B. The kit is dry. C. The outer wrapper is disposed in an appropriate receptacle. D. The kit is unopened.

C. Rationale: When using a pre-packaged kit to set up a sterile field, it is important that the nurse check the expiration date to make sure that it is still valid. It is also important to ensure that the kit is dry and unopened, indicating that the kit is still sterile. Although the outer wrapper is discarded in an appropriate receptacle, this step does not ensure that the contents of the kit are sterile.

Which route of medication administration is most commonly prescribed? A. Subcutaneous B. Intravenous C. Topical D. Oral

D Rationale: Oral administration is the most commonly used route of administration. It is usually the route most convenient and comfortable for the client.

The nurse determines that the sterile field has been contaminated when which action occurs? A. The field is above waist level. B. A sterile object falls within the 1-in (2.5-cm) border of the field. C. The nurse reaches around the sterile field. D. The nurse turns his or her back to the field.

D. Rationale: A sterile field becomes compromised if the nurse turns away from it, if it drops below waist level, if an object falls onto or outside of the 1-in (2.5-cm) border of the field, or if the nurse reaches over the sterile field.

The client is prescribed digoxin 0.125 mg PO every day. The nurse obtains the medication from unit stock and discovers that digoxin only comes in a 0.25-mg tablet. How many tablets of digoxin should the nurse administer to the client? A. 1.5 tablets B. 1 tablet C. 2 tablets D. 0.5 tablet

D. Rationale: Because the client only needs 0.125 mg of digoxin per day, the nurse would need to split the 0.25-tablet in half to obtain the correct dose; therefore, the nurse should administer 0.5 tablet to the client. Administering 1, 1.5, or 2 tablets would be too much medication for the client. 0.125 mg ÷ 0.25 mg/tablet = 0.5 tablet

A nurse is preparing a medication from a glass ampule. After breaking the ampule, the nurse notes blood on the gauze pad. What should the nurse do first? A. Administer the medication as prescribed B. Clean and bandage the wound C. obtain a new gauze pad D. discard the ampule and medication

D. Rationale: Blood on the gauze pad indicates the nurse has been cut while opening the glass ampule. The nurse should first discard the ampule and medication in case contamination has occurred. The nurse would then clean and bandage the wound, and then obtain a new ampule and prepare a new dose, using a new gauze pad. After preparing a new dose of medication, it would be administered as prescribed. The injury should be reported as per facility policy.

The nurse is preparing to administer medications to a client with a gastric tube. What is the best way to determine which medications can be crushed? A. Call the manufacturer. B. Ask another nurse. C. Call the health care provider. D. Check the drug guide.

D. Rationale: Certain solid dosage medications can be crushed and combined with liquid, but the nurse must check the drug guide first before administering to a client with a gastric tube. Calling the health care provider is unnecessary because the prescription has already been given. Asking another nurse or calling the manufacturer of the medication can provide this information, but these methods are not as accurate as checking the drug guide.

The client tells the nurse that the medication in the cup is not the same as the medication he took the day before. The client is insistent that the medication is not the one prescribed. Which action by the nurse would be least appropriate? A. Verify what is written on the medication administration record with the client's chart. B. Contact the health care provider to determine if the medication prescribed is correct. C. Check the drug package with what is written on the medication administration record. D. Tell the client that he must take this medication because it is prescribed by the health care provider.

D. Rationale: If a client voices concerns about a medication to be administered, the nurse would verify that the medication is indeed the one that the client is to receive. Telling the client that he or she must take the medication is inappropriate because it is threatening and coercive. The nurse would double-check the drug package with the medication administration record and verify that the order on the client's chart has been transcribed correctly to the medication administration record. In addition, if there is still some question, the nurse would contact the client's health care provider to ensure that the medication order is correct.

The nurse has administered a client's medication. Which action would be most appropriate if the client vomits immediately, or soon after administration? A. Check the medication to see if vomiting is indicated. B. Do not re-administer the medication until the next dose is due. C. Clean up the vomit/emesis and re-administer the medication. D. Check the vomit/emesis for pills or pill fragments and call the client's health care provider.

D. Rationale: If the client vomits after medication is administered, the nurse should check the vomit/emesis for pills or pill fragments. Then, findings should be reported to the client's health care provider, and the mess should be cleaned up. If the pills, or pill fragments, are found in the vomit, the health care provider may ask that the medication be re-administered. If no pills or pill fragments are found in the vomit, the health care provider would probably ask that the medication not be re-administered because the client might receive too large a dose.

The nurse is observing a sterile field that was prepared by another staff member. Which, if present, would indicate that the sterile field is contaminated? A. Sterile gloves, removed from the outer wrapping, 4 inches away from the edge of the sterile field B. Sterile drape hanging off the work surface C. Sterile 4 × 4 gauze dressings, removed from the packaging and placed in the middle of the sterile field D. Sterile drape positioned with the moisture-proof side facing up

D. Rationale: If the sterile drape is placed with the moisture-proof side up, it will become contaminated if it gets wet. Although any portion of a drape that hangs off the work surface is considered contaminated, it would not mean that the sterile field itself is contaminated. Sterile gauze being placed in the middle of the sterile field and sterile gloves being placed 4 inches away from the edge of the sterile field would not contaminate it, as these are proper procedures.

After reviewing the skills for administering different medications, a student nurse demonstrates the need for additional review when she does takes which action? A. Asks the client if he or she would like the medication in a cup or in the hand. B. Documents in the MAR that the medication was taken by the client. C. Takes the medication instead of leaving it at the client's bedside. D. Leaves before verifying that the client has swallowed the medication.

D. Rationale: It is important to verify that the client has swallowed the medication before leaving the room and document it in the MAR. This ensures that the client has actually taken the medication so that accurate follow-up with the client can be performed.

The nurse is teaching a client how to prepare and administer liquid medications. The client has been on other types of medications for several years. What common error would be most appropriate for the nurse to include in teaching this client? A. An oral syringe is the only way to administer liquid medications. B. If the measurement is a little incorrect, it is not a problem. C. When sharing medication with others, they should take the same dose. D. The client can use any type of measuring device.

D. Rationale: One common error with liquid medicines involves taking the wrong amount due to use of an inaccurate device such as a kitchen teaspoon. Using an oral syringe or other graduated measuring device is necessary to deliver an accurate dose. The client does not have to use one specific device but must use something that measures accurately. There is confusion between different dose measurements. For example, liquid medicines can be dosed in household measurements (teaspoons or tablespoons) or in the metric system (milliliters). Using a household implement often leads to guessing and an underdose or overdose of medication. Clients must be taught that a "teaspoon" from the kitchen is not the same as a medication teaspoon. It is never acceptable to share prescription medications with other people; they may be harmed because the medication was not prescribed for that individual. People often "save" medication, and this is an unsafe practice.

The nurse has prepared a sterile field with the necessary sterile supplies. The nurse begins to perform the care and realizes that an item is missing. What action would be appropriate? A. Complete the care right up to the step of the missing item, then go get it. B. Skip the part of the care that requires the missing item. C. Leave the client and the room to obtain the missing item. D. Call someone to bring in the necessary item to the client's room.

D. Rationale: So as not to disrupt the prepared sterile field, when the nurse notices that an item is missing, the most appropriate action would be to call someone to bring the necessary item to the client's room. If the nurse leaves the room at any time to obtain an item, the sterile field is no longer considered sterile and an entirely new sterile field would need to be set up. Skipping the part of care that requires the missing item would be inappropriate.

What is the best way for the nurse to remove air bubbles from the syringe after drawing up medication from an ampule? A. With the needle still in the ampule, tap the syringe, and push on the plunger. B. Insert the tip of the needle into the ampule and invert the ampule until the air is removed. C. Tap the withdrawn syringe, reinsert the needle, and withdraw a small amount of fluid. D. Withdraw the needle from the ampule, tap the syringe, and push on the plunger.

D. Rationale: The best way to remove air bubbles from the syringe is to wait until the needle has been withdrawn to tap the syringe and expel the air carefully by pushing on the plunger. Leaving the needle in the solution and pushing on the plunger may cause the solution to spill over the ampule. Taping the withdrawn syringe, reinserting the needle and withdrawing more solution will not assist in removing air bubbles. Inserting the tip of the needle into the ampule and inverting the ampule is the procedure for withdrawing medication, not removing air.

The nurse is opening a package containing a sterile drape to establish a sterile field. Which occurrence would indicate that the nurse had contaminated the sterile drape? A. The nurse places the shiny side of the drape facing down. B. The nurse touches the sterile drape by its corners. C. The nurse allows the drape to unfold gently. D. The nurse allows the drape to touch his or her body.

D. Rationale: The drape becomes contaminated when it touches anything that is not sterile, such as the nurse's body clothing, or a non-sterile surface. Touching the drape by the corners and allowing it to unfold gently maintains sterility. The shiny or blue side is the moisture-proof side that prevents contamination of the field if it becomes wet.

Which should be documented by the nurse? A. The fact that the nurse donned gloves two different times during a procedure. B. The fact that the nurse washed her hands before a procedure. C. The specific items that the nurse transferred into a sterile field. D. The fact that sterile technique was used for a given procedure.

D. Rationale: The fact that sterile technique was used for a given procedure should be documented, but the other items listed do not need to be documented, as they are standard procedure.

A nurse has administered a pain medication to the client. What should the nurse do next? A. Leave the client alone. B. Call the health care provider. C. Put all four side rails up. D. Reassess the client.

D. Rationale: The most appropriate action after administering pain medication is to reassess the client for the right response. The client should not be left alone without access to the call bell and should be instructed not to get out of bed without help. All four side rails should not be up; this is a form of restraint.

The nurse puts on sterile gloves in preparation for a sterile central line dressing change. The nurse realizes that the bed is too low to complete the procedure adequately. What action does the nurse take? A. Take off the sterile gloves. B. Place clean gloves over the sterile gloves. C. Raise the bed using one finger. D. Ask someone to raise the bed.

D. Rationale: The nurse can ask someone else to raise the bed. This may be the client or anyone in the room capable of assisting. Other than this, the nurse would need to call someone to come in and raise the bed or change the gloves for new sterile gloves. Once the nurse uses any part of the sterile glove to touch a non-sterile surface, that glove is no longer sterile. It makes no difference if the nurse removes the sterile gloves; once they are removed they cannot be reused safely. Placing clean gloves over the sterile gloves destroys the sterility.

The nurse prepares for a sterile dressing change on one end of the table by opening a sterile field and dropping the supplies onto it. The nurse needs to gather additional supplies remaining on the other side of the table. What action does the nurse take? A. Prepare a second sterile field to cover the entire table surface. B. Reach toward the other end of the table and pick up the supplies. C. Discard the current sterile field and supplies and begin again. D. Take a few steps around the table to pick up the additional supplies.

D. Rationale: The nurse can step around the edge of the table, without turning his or her back on the sterile field, to gather the remaining supplies. Reaching across the current sterile field would be a reason to discard all the supplies and the field due to contamination. The table does not need to be completely covered with sterile drapes.

While donning sterile gloves for a client's dressing change, the nurse rips the cuff while pulling it over a wristwatch. What is the appropriate nursing action? A. Place a new sterile glove over the ripped glove. B. Use the ripped glove for nonsterile actions. C. Continue with the dressing change. D. Obtain a new pair of sterile gloves.

D. Rationale: The nurse must change gloves. The ripped glove is not sterile, nor is the wrist which should be covered by the cuff. The intact glove may also be contaminated because the fingers were in the cuff as it ripped.

What action should the nurse take when changing a sterile dressing on a central venous access device? A. Position the sterile dressing supplies on the table between the nurse and client. B. Place sterile gloves on before removing the existing dressing. C. Leave the bed in a low position if the side rail will need to be lowered. D. Cleanse the central venous access device site while wearing sterile gloves

D. Rationale: The nurse performs site care after applying sterile gloves, including cleansing the site with an antiseptic. Sterile gloves are not needed to remove the existing dressing, and, if used, the gloves must be discarded prior to completing site care and the dressing change. The nurse does not need to leave the bed in the lowest position while at the bedside. The sterile supplies are placed to the side of the nurse so that the nurse does not have to reach across the sterile field to perform care.

The nurse is distributing afternoon medications to the clients. When removing a tablet from a multi-dose bottle, what should the nurse do first? A. Drop tablet into a medication cup. B. a tablet out of the bottle with the fingers. C. Shake a tablet out onto the hand. D. Pour the tablet into the bottle cap.

D. Rationale: The nurse should pour the tablet into the bottle cap and then into a medication cup for each client. The nurse should never let the tablet touch his or her fingers or bare hand. The nurse should drop the tablet into the bottle cap before putting it into a medication cup.

The nurse is preparing to split medication for client administration. What method should the nurse use to split the medication? A. Split the pill by hand, wearing gloves. B. Place the pill in the pill grinder and twist closed. C. Divide the pill using a knife. D. Place the pill in the pill splitter and close.

D. Rationale: The nurse should wear gloves and place the medication in the pill splitter and close down on the score on the tablet to split in half. The tablet should not be split by hand, smashed, or ground. The tablet may split in another area other than the score, rendering half with too much or not enough medication for the client.

The nurse is performing a sterile dressing change. What action would require the nurse to put on a new pair of gloves? A. The nurse keeps both hands above waist level. B. The nurse picks up a sterile dressing from the sterile field. C. The nurse touches one glove to the other glove. D. The nurse touches the client's skin with one hand.

D. Rationale: The nurse would need to put on a new pair of gloves if the ones being worn became contaminated, such as by touching the client's skin with one of the gloves. Picking up a sterile dressing from the field, keeping both hands above waist level, or touching one glove to the other glove would not cause contamination and thus not necessitate putting on a new pair of gloves.

The nurse assists a new nurse to add items to a sterile field. Which action by the new nurse requires further instruction? A. The nurse grasps the remaining flap of the wrapper and pulls back toward wrist. B. The nurse keeps hands and wrists on the outside of the wrapped sterile item. C. The nurse holds wrapped item in dominant hand to open, opening top flap away from body. D. The nurse drops the item from the wrapper into the side of the sterile field.

D. Rationale: The outer edges of the sterile field are considered nonsterile. Dropping items into the outer edges of the field causes those items to be considered contaminated. Items are dropped toward the center of the field from approximately six inches above the surface of the field. The nurse opens the package outward over the hands, maintaining the sterility of the item inside the package. Items are typically held in the non-dominant hand while the dominant hand pulls the package open.

The nurse has prepared a sterile field using a pre-packaged kit. Which would be important for the nurse to keep in mind? A. No other sterile items can be added to the sterile field at this point. B. The items contained in the kit are considered clean. C. Sterile gloves are not needed to obtain any items from the field. D. The field is contaminated if it is out of the nurse's site.

D. Rationale: When a pre-packaged kit is used to create a sterile field, it and everything it contains are considered sterile. The kit would become unsterile if the field is out of the nurse's site or if it was below waist level. Other sterile items can be added to the sterile field, and the nurse would need to wear sterile gloves to obtain any items from the field.

When setting up a sterile field, the nurse opens a sterile package prepared by the facility. Which action would the nurse take first? A. Pull the corners of the wrapper back toward the wrist. B. Reach over the package to open the side flaps. C. Hold the package in the non-dominant hand. D. Unfold the top flap away from the body.

D. Rationale: When opening a sterile package prepared by a facility, the nurse would hold the package in the dominant hand with the top flap facing away from the body. The nurse would first unfold the top flap away from the body, then the side flaps (reaching under the package to open the opposite side flap), and lastly the flap closest to the body. The nurse would then pull the corners of the wrapper back toward the wrist.

What is the best method for opening an ampule of morphine for a prescribed IV push? A. Place a paper towel over the vial and twist the top and bottom in opposite directions to break the top at the scored line at the neck. B. Wrap an alcohol wipe around the neck and gently twist the top to break the scored line at the neck. C. Use a gloved hand to gently apply pressure to the top of the ampule until the top breaks off at the scored line.at the neck. D. Wrap a small gauze pad around the neck and use a snapping motion to break the top at the scored line in the neck.

D. Rationale: When opening an ampule, the nurse would use a small gauze pad or dry alcohol wipe to hold the top and use a snapping motion to break off the top of the ampule at the scored line. The pad protects the fingers from the glass as the ampule is opened. A twisting motion is not recommended. Applying pressure with a gloved hand to the top of the ampule will not effectively break the scored line at the neck.

The nurse has gathered several individually packaged dressings for a sterile dressing change. When adding these dressings to the sterile field, which action would the nurse take? A. Tear open the package across the top. B. Pull the top cover off at an angle. C. Cut the package open with sterile scissors. D. Peel the edges apart with both hands.

D. Rationale: When opening sterile packages to be added to the sterile field, the nurse would hold the package in one hand and pull back the top cover with the other hand, or peel the edges apart using both hands. The package would not be torn or cut open, nor would the top cover be pulled off at an angle.

The nurse is preparing to put on sterile gloves. When putting on the first glove, how does the nurse grasp the folded cuff? A. Thumb and fifth finger B. Index and second finger C. Second, third, and fourth fingers D. Thumb and forefinger

D. Rationale: When putting on sterile gloves, the nurse grasps the folded cuff of the first glove with the thumb and forefinger of the opposite hand. The other grasping positions are awkward and not attempted.

The nurse is putting on sterile gloves. Which principle would be important to keep in mind? A. The cuffs of the gloves should be adjusted as each glove is applied. B. The outer edge of the cuff is used to pick up the glove to be put on. C. The inner package should be placed on the surface with the cuff side away from the body. D. The hands should remain above waist level at all times.

D. Rationale: When putting on sterile gloves, the nurse must ensure that the hands remain above waist level at all times. The inner package should be placed on the surface with the cuff side toward the body. The inner aspect of the cuff is used to put on the glove for the dominant hand, while the gloved fingers are slid under the cuff of the second glove to apply it. The cuffs are adjusted once both gloves are on.

When removing soiled gloves, which should the nurse do first? A. Turn the glove inside out as it is being pulled off. B. Slide the fingers under the glove at the wrist. C. Peel the glove off over the other glove D. Grasp the outside of one glove with the opposite gloved hand.

D. Rationale: When removing soiled gloves, the nurse would grasp the outside of one glove with the opposite gloved hand and peel it off, turning the glove inside out as it is pulled. The removed glove is held in the remaining gloved hand. The nurse would then slide the fingers of the ungloved hand under the remaining glove at the wrist and peel off the glove over the first glove, containing one glove inside the other.

The nurse is preparing a sterile field using a pre-packaged kit. After performing hand hygiene, which action would the nurse take next? A. Place the package in the center of the work surface B. Place the work surface at waist height C. Remove the outer wrapper from the kit D. Confirm the client's identity

D. After performing hand hygiene, the nurse would confirm the client's identity. The nurse would then ensure that the work surface is at waist height and place the package in the center of the surface. Lastly, the nurse would open the outside cover of the package and remove the kit.