(Fund Ch 29) PrepU
A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration? a. Deltoid b. Vastus lateralis c. Biceps brachii d. Scapula
a. Deltoid The deltoid and ventrogluteal sites are more appropriate for adults than the vastus lateralis. The scapula is a site for an intradermal injection. The biceps brachii muscle is not used for intramuscular injections.
The nurse is beginning to administer oral medications to a client. The client states, "I haven't taken that pill before. Are you sure it's correct?" The nurse rechecks the CMAR/MAR and finds that the medication is scheduled to be administered. Which response is most appropriate? a. "Don't take that pill yet. I will verify that the medication was ordered by your primary care provider." b. "Go ahead and take it, and then I'll check with your primary care provider about it." c. "It's listed here on the CMAR/MAR, so you should take it." d. "It wouldn't be listed on this CMAR/MAR if it wasn't prescribed for you."
a. "Don't take that pill yet. I will verify that the medication was ordered by your primary care provider." This nurse should verify the medication with the prescriber. By this action, the nurse is adhering to the five "rights" of medication administration. A nurse and client should both be aware of medications that are prescribed and why they are prescribed. A nurse should not tell a client they should take a medication just because it is listed on the CMAR/MAR, nor should the nurse tell them to take it and they will follow up later. This could be a medication error.
Which client does the nurse recognize will require an intramuscular administration of the medication instead of an intravenous administration? a. client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination b. client who is beginning treatment with chemotherapy following a diagnosis of ovarian cancer c. client who is diagnosed as having sepsis and is prescribed antibiotic therapy d. client who is in the emergent phase of a 50% partial-thickness (second-degree) burn and requiring medication for pain
a. client who is low risk for hemorrhage and prescribed the Hepatitis B vaccination The hepatitis B vaccine is administered intramuscularly. Recombivax HB, a form of the hepatitis B vaccine, may be administered subcutaneously to clients who are at high risk for hemorrhage. This client is low risk. Medications for the clients experiencing the situations listed would be administered intravenously.
The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed? a. miconazole b. oxymetazoline c. bisacodyl d. timolol
a. miconazole The nurse anticipates that miconazole, a vaginal cream, will be prescribed for a yeast infection. Oxymetazoline is a nasal decongestant used to alleviate congestion; bisacodyl is a rectal suppository used for softening stool; timolol is an eye drop used to treat glaucoma.
The nurse is preparing to administer two IV medications. What is the appropriate nursing action? a. Prepare to administer through two separate tubes. b. Administer the drugs through the same tubing. c. Consult a current drug reference book for IV compatibility. d. Hold one medication for an hour and administer it after the first medication.
c. Consult a current drug reference book for IV compatibility. The nurse should consult a current drug reference book for compatibility before administering two IV medications. Other answers are incorrect.
Which instruction should the nurse give to a client to ensure that a nasal medication is deposited within the nose rather than into the throat? a. "Place a rolled towel beneath the neck if you are unable to sit." b. "Aim the tip of the container toward the nasal passage." c. "Breathe through your mouth as the drops are instilled." d. "Remain in the sitting position for 5 minutes."
b. "Aim the tip of the container toward the nasal passage." Aiming the tip of the container toward the nasal passage will deposit the drugs within the nose rather than into the throat. Place a rolled towel beneath the neck if the client cannot sit will provide support and aid in positioning. Breathing through the mouth as the drops are instilled is not the correct action for nasal drop administration. Remaining in the sitting position for 5 minutes will promote local absorption.
What is the best response by the nurse when a client asks about the side effects of using nasal spray? a. "Long-term use of nasal sprays can cause difficulty in coordinating breathing." b. "Long-term use of nasal sprays can cause rebound nasal congestion." c. "Long-term use of nasal sprays can repair the nasal passage." d. "Long-term use of nasal sprays can cause an unpleasant taste."
b. "Long-term use of nasal sprays can cause rebound nasal congestion." Saying that long-term use of nasal sprays can cause rebound nasal congestion is correct, as this usually occurs when nasal sprays are used repeatedly by clients. Long-term use of nasal sprays cannot cause difficulty in coordinating breathing; this is more applicable with inhalers than with nasal sprays. Long-term use of nasal sprays do not repair the nasal passage; instead, they damage the nasal passage. Long-term use of nasal sprays does not cause an unpleasant taste; this is more appropriate with inhalers and not nasal sprays.
The nurse is teaching a client about zolpidem CR for sleep. When the client asks, "What does the CR mean?" what is the appropriate nursing response? a. "sustained release" b. "continuous release" c. "extended release" d. "sustained action"
b. "continuous release" The nurse will clarify that CR means "continuous release." XR means "extended release;" SR means "sustained release;" SA means "sustained action."
A client is to take Demerol 35 mg IM. You have Demerol 50 mg per ml. How many ml will you administer? a. 0.5 ml b. 0.7 ml c. 0.9 ml d. 1.3 ml
b. 0.7 ml The nurse will administer Demerol 35 mg or 0.7 ml. 50mg/35mg = 0.7 ml.
An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method? a. a container with enough prescribed medications for several days for a client b. self-contained packets that hold one tablet or capsule for individual clients c. a supply that remains on the nursing unit for use in an emergency d. systems that contain frequently used medication for that unit
b. self-contained packets that hold one tablet or capsule for individual clients The nurse should understand that a unit dose supply method is a method in which self-contained packets hold one tablet or capsule for an individual client. An individual supply is a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay. Some facilities use automated medication-dispensing systems, which contain frequently used medications for that unit, any as-needed (p.r.n.) medications, controlled medications, and emergency medications.
The nurse is teaching a nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct? a. "Pharmacists usually administer chemo drugs." b. "Once the drugs are packaged in the pharmacy, there are no risks in handling the medication." c. "Antineoplastic drugs can be absorbed through the skin." d. "Antineoplastic drugs only target cancer cells."
c. "Antineoplastic drugs can be absorbed through the skin." Antineoplastic drugs are absorbed through the skin and should always be handled with caution. All other options are incorrect.
The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask? a. "Why do you see so many different providers?" b. "Which provider seems to take the best care of you?" c. "Do you get all of your medications filled at the same pharmacy?" d. "How long have you been seeing a variety of providers?"
c. "Do you get all of your medications filled at the same pharmacy?" Polypharmacy is a concern in the older adult population. The nurse will want to know if medications are filled at the same pharmacy, as this is often where pharmacists will note discrepancies in medications prescribed or duplicate orders written by different providers. The other questions posed are not helpful.
A client with diabetes who requires the new placement of an insulin pump asks the nurse how it works. What teaching will the nurse provide? a. "This will be used in addition to giving yourself injections." b. "You will wear this to receive a stream of insulin 24 hours daily." c. "Settings can be adjusted for exercise and illness, and bolus doses can be delivered related to meals." d. "This device contains long-acting insulin."
c. "Settings can be adjusted for exercise and illness, and bolus doses can be delivered related to meals." The nurse will teach that the insulin pump contains rapid-acting insulin and releases ongoing small amounts of insulin (not a stream), and that the client can manually release an additional dose after meals or snacks.
An older adult client has been prescribed a transdermal patch. Which client statement demonstrates the need for further teaching by the nurse? a. "I will remove the patch before I have my MRI tomorrow." b. "When changing patches, I will change the location of application." c. "This medication is likely to work slower on me than on a younger person." d. "I will close the adhesive edges of the patch before I dispose of it."
c. "This medication is likely to work slower on me than on a younger person." The nurse will need to teach the client that the onset of drug action may be faster in an older adult than in a younger adult. All other statements are appropriate and do not require further education.
Regarding medication administration, what must occur at the change of shifts? a. The client's medications must be drawn up. b. The medications for the division are counted. c. The narcotics for the division are counted. d. Only the LPNs on the division count medications.
c. The narcotics for the division are counted. Health care facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine).
A nurse is taking care of a 56-year-old man with end-stage liver disease. The nurse has a prescription to give 20 g of lactulose every 6 hours to treat the client's hepatic encephalopathy. On hand, the nurse has containers of lactulose that have 30 g in 45 mL. How many milliliters is the nurse going to administer every 6 hours to the client? a. 15 mL b. 22.5 mL c. 67.5 mL d. 30 mL
d. 30 mL The formula to calculate the correct medication amount is: (Dose on hand/Quantity on hand = Dose desired/X). If you use this for this scenario, you would have 30 g/45 mL = 20 g/X, where X = 30 mL.
The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client? a. 10 to 15 degrees b. 20 to 30 degrees c. 45 degrees d. 90 degrees
d. 90 degrees Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle. Other answers are incorrect.
Children's medication dosages are most often calculated using the child's body surface area and: a. Age b. Diagnosis c. Height d. Weight
d. Weight Children's dosages are most often calculated using the child's weight or body surface area.
The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse? a. "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes." b. "As a registered nurse you will not have to perform skills like bathing and administering medications unless you want to." c. "You will be able to perform all the skills the health care provider allows you to perform when you become a nurse." d. "Perhaps it is important to think and decide if nursing is the profession for you. There are other roles in health care for you to consider besides becoming a nurse."
a. "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes." The administration of medications to clients is a core nursing function that involves skillful technique and consideration of the client's development, health status, and safety. Also, the nursing process is often applicable to the skills of medication administration. Informing the new nurse that this profession may not be the one for them is not professional and does not foster respect for the person or the question raised. Professionalism is expected with each interaction with clients, family members and other health care members, including nursing students.
The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective? a. "Reconstitution is the process of adding liquid, known as diluent, to a powdered substance." b. "Reconstitution is a sealed glass cylinder of parenteral medication with an attached needle." c. "Reconstitution is a glass or plastic container of parental medication with a self-sealing rubber stopper." d. "Reconstitution is a sealed glass drug container that must be broken to withdraw the medication."
a. "Reconstitution is the process of adding liquid, known as diluent, to a powdered substance." Reconstitution is the process of adding liquid, known as diluent, to a powdered substance. A sealed glass cylinder of parenteral medication with an attached needle is a refilled cartridge, not reconstitution. A glass or plastic container of parental medication with a self-sealing rubber stopper is a vial, not reconstitution. A sealed glass drug container that must be broken to withdraw the medication is an ampoule, not reconstitution.
The nurse is preparing to administer meperidine as an intramuscular injection in an adult client's deltoid site. Which needle should the nurse select for this injection? a. 1-inch; 22-gauge b. 5/8-inch; 24-gauge c. 1½-inch; 18-gauge d. 2-inch; 18-gauge
a. 1-inch; 22-gauge IM injections using the deltoid site require a 20- to 25-gauge needle that is between 1 and 1½ inches (2.5 and 4 cm) in length.
A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? a. 1500 b. 1200 c. 2000 d. Wait until day 5 of treatment.
a. 1500 Peak levels are drawn shortly after the drug is administered. The best choice is 1500 because it closely follows the time of infusion, which is when the drug concentration would be highest.
The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear? a. 5 minutes b. 10 minutes c. 15 minutes d. 20 minutes
a. 5 minutes When ear drops are to be administered in both ears, the nurse would wait 5 minutes after giving the ear drops in the first ear before administering the ear drops into the second ear. This avoids causing the medication to run out immediately after administration. Other times are longer than are needed between ears.
The nurse is reviewing the plan of care for several clients who have prescriptions for intravenous medications. The nurse understands that which client is at the highest risk for greater effect of the IV medication? a. 73-year-old client diagnosed with liver disease b. 16-year-old client diagnosed with left radial fracture c. 35-year-old client diagnosed with migraines d. 45-year-old client diagnosed with lung cancer
a. 73-year-old client diagnosed with liver disease Older adults have a decrease in plasma protein, which is needed to bind and inactivate the medication in the bloodstream. The decrease in plasma proteins can increase the amount of medication circulating, which increases the effects. Decreased liver and kidney function also increases the amount of medication in the blood. The other options can have a risk, but they are not the highest.
After inserting an intravenous catheter into a client's vein, the nurse does not obtain blood return. What is the appropriate nursing action? a. Change the catheter insertion site. b. Obtain a larger bore catheter. c. Gently insert the IV catheter further into the vein. d. Begin infusion of IV fluids and document the procedure.
a. Change the catheter insertion site. If a blood return is not obtained, the IV catheter is not appropriately placed. The nurse will remove the IV catheter and change the site. Other actions are incorrect.
A nurse is providing care for a client who has a history of dementia. Which method should the nurse use in order to determine the client's identity prior to medication administration? a. Check the client's identification band. b. Ask the client his name prior to giving the drug. c. Cross-reference the MAR with the client's medical record. d. Enlist the help of a colleague who is familiar with the client.
a. Check the client's identification band. For all clients, the preferred method of confirming identity is to read the client's identification band. The next step, if possible, is for the nurse to state their name. Cross-referencing with the MAR and the client's medical record does not allow for any interaction with the actual client. Enlisting the help of a colleague who is familiar with the client is not appropriate.
An oral medication has been ordered for a client who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration? a. Check the tube placement before administration. b. Have the client swallow the pills around the tube. c. Flush the tube with 30 to 40 mL saline before medication administration. d. Bring the liquids to room temperature before administration.
a. Check the tube placement before administration. The nurse must first verify that the tube is in place and not in the lungs prior to administering the medication. Next, the nurse can bring the liquids to room temperature. Typically the tube is flushed with 15 to 30 mL of water for adults (5 to 10 mL for children). The nurse should never have the client swallow the pills if the client has an nasogastric tube.
What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity? a. Therapeutic range b. Peak level c. Trough level d. Half-life
a. Therapeutic range Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. Peak level is the highest plasma concentration. Trough level is the point when the drug is at the lowest concentration. Half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.
A client with chronic obstructive pulmonary disease (COPD) has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication? a. Use a spacer or extender with the metered-dose inhaler. b. Provide oxygen therapy 30 minutes prior to administration. c. Provide multiple puffs of the medication in rapid sequence. d. Place the inhaler as deeply into the client's mouth as is comfortable.
a. Use a spacer or extender with the metered-dose inhaler. The use of an extender or spacer ensures that the client receives as much of the inhaled medication as possible. MDIs are placed 1 or 2 inches (2.5 or 5 cm) in front of the mouth, not deeply into the mouth. Oxygen therapy prior to administration does not aid in delivery. Multiple puffs, if ordered, are given after 1 to 5 minutes.
The nurse is preparing to administer a medication to a client when the client states, "Last time I took that medication, I broke out in hives." What is the priority action by the nurse? a. Withhold the medication and notify the health care provider that ordered the medication b. Administer the medication, the reaction may not occur again c. Administer the medication and monitor the client for 30 minutes after administration d. Substitute another medication with the same action
a. Withhold the medication and notify the health care provider that ordered the medication Whenever a client reports being allergic to a medication, the nurse should withhold the medication and notify the provider so that something else may be ordered. The medication should never be administered due to the risk of a potential anaphylactic reaction. The nurse may not substitute any medication without a providers order.
Which client would most likely require placement of an implantable port? a. a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy b. an 18-year-old man s/p gunshot wound in the ICU requiring multiple blood transfusions c. a 12-year-old girl with sickle cell anemia requiring frequent pain medication administration d. a 45-year-old man with a history of colon cancer that is currently in remission
a. a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy This client needs frequent IV access. A central port is easily accessed for chemotherapy sessions, then the access is discontinued even though the port remains in place subcutaneously. A central port also allows for the infusion of chemotherapy into a central vessel; this is important because chemotherapy is caustic and severely damages peripheral vessels.
To which client would the nurse be most likely to administer a p.r.n. medication? a. a client who is reporting pain near the surgical site b. a client who requires daily medication to control hypertension c. a client who is experiencing severe and unprecedented chest pain d. a client whose asthma is treated with inhaled corticosteroids
a. a client who is reporting pain near the surgical site A report of "breakthrough" pain, especially postsurgery, would likely require the nurse to administer a p.r.n. analgesic. A new onset of chest pain would likely require a stat order, while longstanding treatment of hypertension and asthma would likely include standing orders for relevant medications.
The nurse is preparing to administer medication to a client with high blood pressure. When will the nurse document administration in the medication administration record (MAR)? a. after completion of drug administration b. during preparation of the medication for administration c. while administering the medication at the bedside d. at the end of the nurse's shift before giving report
a. after completion of drug administration The nurse documents administration after giving medications each time a drug is given, without delay, so that care is recorded appropriately at the time it is given. The nurse never documents administration of medications ahead of delivery, nor does documentation take place during the actual delivery of medication.
The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not? a. aspirating for a blood return b. inserting the needle at a 90-degree angle c. withdrawing the needle and immediately releasing the taut skin d. waiting 10 seconds with the needle still in place and the skin held taut
a. aspirating for a blood return Aspirating for a blood return is correct, as this will determine if the needle is in the blood vessel. Inserting the needle at a 90-degree angle is incorrect, as this directs the needle in the muscles. Withdrawing the needle and immediately releasing the taut skin is incorrect, as this creates a diagonal path to prevent leaking in the subcutaneous layer of the tissue. Waiting 10 seconds with the needle still in place and the skin held taut is incorrect, as this provides time to distribute the medication in a larger area.
A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes? a. bolus administration b. electronic infusion device c. continuous administration d. secondary administration
a. bolus administration Because the entire dose is administered quickly, bolus administration has the greatest potential to cause life-threatening changes should a drug reaction occur. An electronic infusion device, continuous administration, and secondary administration do have the potential to cause life-threatening changes, but not to the same degree as a bolus administration, since the rate at which medication is administered is not as fast as during a bolus.
Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection? a. checking for documented allergies to food or drugs b. preparing the syringe with the medication c. cleaning the area with an alcohol swab d. gathering all the equipment needed
a. checking for documented allergies to food or drugs Checking for documented allergies to food or drugs is done to ensure safety and is therefore correct. Preparing the syringe with the medication is incorrect because this is considered planning, not assessment. Cleaning the area with an alcohol swab is implementing, not assessing. Gathering all the equipment needed is also considered planning.
A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle? a. intradermal b. subcutaneous c. intramuscular d. intravenous
a. intradermal When giving an intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. When the nurse administers a subcutaneous injection, the angle of entry is either 45 degrees or 90 degrees, whereas for intramuscular injections, the angle is 90 degrees. Intravenous injections are instilled into the veins of the client at an angle of around 15 degrees, but only if no venous access port is in place.
A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understands that this type of infusion is used for which situation? a. medications that need to be infused over 20 to 60 minutes b. medications that are given over 1 minute for rapid therapeutic effect c. medications that can be given through a capped intravenous port d. medications that are toxic if given over short periods
a. medications that need to be infused over 20 to 60 minutes Intermittent infusions are used for medications that need to be administered for an intermediate length of time, usually 20 to 60 minutes. The intravenous push technique is used for medications that can be given over 1 minute for rapid therapeutic effect, and may be given into a continuously infusing IV set or into a capped IV port. The continuous infusion technique is used for medications that are toxic if given over short periods.
Which medications are dropped into the ear to treat ear infections or to soften and remove ear wax? a. otic b. ophthalmic c. parenteral d. nasal
a. otic Otic medications are administered in the ear. Ophthalmic medications are administered in the eyes. Parenteral medications are given by injection or infusion.
The nurse is preparing to apply nitroglycerin paste. After checking the order, washing hands, checking the client's identity, and applying gloves, which is the next nursing action? a. removing prior application and any remaining residue from skin b. covering application paper with plastic with transparent semipermeable dressing c. squeezing prescribed amount of paste from tube onto application paper d. using wooden applicator to spread paste over the paper
a. removing prior application and any remaining residue from skin The nurse will remove one application and residue before applying another, as this prevents excessive drug levels when a new application is placed. The nurse will then proceed to squeeze the paste onto the paper, spread the paste over the paper, apply the paper, and cover it with a transparent semipermeable dressing.
What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal? a. to determine the extent to which the client responded to the drugs b. to administer timely emergency treatment c. to implement measures to reduce the transmission of microorganisms d. to prevent interfering with test results
a. to determine the extent to which the client responded to the drugs Determining the extent to which the client has responded to the drugs is correct, as this allows the nurse to observe the area for signs of local reaction in which the standard time is 24-48 hours. Ensuring that emergency treatment is quickly administered is incorrect since the nurse is to observe the client for allergy to the test in the first 30 minutes. Reducing the risk for the transmission of microorganisms is incorrect since this could be achieved by the nurse removing gloves and performing hand hygiene immediately after administering the drug. Preventing interference with test results is incorrect, as the nurse could instruct the client not to rub the area.
A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which action should the nurse perform when administering oral medication to the client? a. Prepare the exact dosage of medication in front of the client. b. Avoid administering medication prepared by another nurse. c. Bring the prescribed medication in a ceramic cup or glass container. d. Check the label of the medication container three times at the bedside.
b. Avoid administering medication prepared by another nurse. A nurse should never administer medications prepared by another nurse. The nurse administers only those medications that she has prepared. The nurse should prepare and bring oral medications to the client's bedside in a paper or plastic cup, not in a glass container or ceramic cup, in order to avoid accidents and spills. The nurse checks the label of the medication container three times when preparing it, not when administering it to the client.
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. Document the medication dose as not administered. b. Call the pharmacy to request a supply change. c. Cut the second tablet in half using a pill splitter. d. Administer one tablet until the issue is resolved.
b. Call the pharmacy to request a supply change. 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.
A nurse is applying a vaginal cream to a client with a fungal infection. Which guideline is recommended for this application? a. Position the client in a left side-lying position. b. Cleanse area at vaginal orifice with washcloth and warm water. c. Wipe from the sacrum to the vaginal orifice upward (back to front). d. Spread the labia with dominant hand and introduce the applicator gently with the nondominant hand.
b. Cleanse area at vaginal orifice with washcloth and warm water. The procedure for applying a vaginal cream is as follows: Position the client so that she is lying on her back with the knees flexed. Spread labia with fingers, and cleanse area at vaginal orifice with washcloth and warm water, using a different corner of the washcloth with each stroke. Wipe from above the vaginal orifice downward toward the sacrum (front to back). Spread the labia with the nondominant hand and introduce the applicator with the dominant hand gently, in a rolling manner.
A nurse is administering a hepatitis B immunization injection to an adult clent. Which site would the nurse choose for this injection? a. Vastus lateralis site b. Deltoid muscle site c. Ventrogluteal site d. Dorsogluteal site
b. Deltoid muscle site Hepatitis B virus vaccine is one medication that should be given in the deltoid muscle in adults to induce adequate levels of the antibody. The vastus lateralis muscle and the ventrogluteal muscle can be used for other intramuscular injections. The dorsogluteal muscle is no longer a preferred site for intramuscular injections.
A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication? Select all that apply. a. Inform the nurse manager about the situation. b. Identify the reason for not administering. c. Circle the scheduled time on the MAR. d. Discuss the reason for refusal with the client. e. Report the situation to the prescriber.
b. Identify the reason for not administering. c. Circle the scheduled time on the MAR. e. Report the situation to the prescriber. When a client refuses the administration of a medication, the nurse needs to mention the reason why she did not administer the medication, circle the scheduled time on the MAR, and report the situation to the prescriber. The nurse should inform the prescriber, not the nurse manager, about the situation. The nurse does not need to discuss the situation with the client; instead, the nurse should document the reason for not administering the medication.
To convert 0.8 grams to milligrams, the nurse should do which of the following? a. Move the decimal point 2 places to the right. b. Move the decimal point 3 places to the right. c. Move the decimal point 2 places to the left. d. Move the decimal point 3 places to the left.
b. Move the decimal point 3 places to the right. To convert a larger unit into a smaller unit, move the decimal point to the right (the new number is larger than the original). 1000 milligrams (mg) is equal to 1 gram (g); therefore 0.8 g is multiplied by 1000 (which is equivalent to moving the decimal point 3 places to the right) to determine how many mg it is equivalent to.
The nurse is caring for a client with visual impairment who has been prescribed two different types of eye drops. Which nursing intervention will best assist the client in differentiating between the bottles of drops? a. Write the names of the medications on the bottle. b. Place a rubber band snugly around one of the bottles. c. Color code the bottles with different colors of pens. d. Teach the client to place bottles on different ends of the table.
b. Place a rubber band snugly around one of the bottles. The client with visual impairment will best benefit from a tactile difference between bottles; therefore, placing a rubber band snugly around one bottle is the best approach. Names written on the bottles may be difficult for the client with visual impairment to read, and color-coding may not work if the client is colorblind. Placing bottles on different ends of the table can be confusing if the client forgets which medication is which.
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. Ask the client to report any dizziness and lightheadedness. d. Teach the client to use the call bell whenever getting out of bed.
b. Set the antihypertensive dose aside pending assessment. 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.
A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection? a. Sites commonly used for a subcutaneous injection are the inner surface of the forearm and the upper back, under the scapula. b. Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. c. Subcutaneous injections are administered at a 30- to 45-degree angle based on the amount of subcutaneous tissue present. d. Pinching is advised for obese clients to lift the adipose tissue away from underlying muscle and tissue.
b. Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. Sites commonly used for an intradermal injection are the inner surface of the forearm and the upper back, under the scapula. Various sites may be used for subcutaneous injections, including the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crests), the anterior aspects of the thigh, the upper back, and the upper ventrogluteal area. Subcutaneous injections are administered at a 45- to 90-degree angle, based on the amount of subcutaneous tissue present and the length of the needle. Pinching is advised for thinner clients and when a longer needle is used, to lift the adipose tissue away from underlying muscle and tissue.
A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response? a. Input the order into the computerized provider order system. b. Tactfully request the provider to input the order into the computerized provider order system. c. Refuse to implement the order and notify the nurse manager. d. Have another nurse witness and record the order into the medication administration record (MAR).
b. Tactfully request the provider to input the order into the computerized provider order system. Providers are to enter their own orders when they are physically present. It is appropriate for the nurse to tactfully request that the provider do so. The nurse should not input the order, nor refuse to implement it.
Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler? a. The nurse should instruct the child to prolong his/her inhalation. b. The nurse should use a nebulizer to administer the medication. c. The nurse should assess the child's mucous membranes. d. The nurse should provide simple written instructions.
b. The nurse should use a nebulizer to administer the medication. The nurse's use of a nebulizer to administer the medication is correct, as this is an alternative to administering an inhalant for young children. Instructing the child to prolong his/her inhalation is incorrect, as this is used to reduce side effects of using inhalants. Assessing the child's mucous membranes is incorrect, as this action is used to identify any break in the continuity of the membranes and will not assist with the coordination of inspiration. Providing simple written instructions is incorrect, as this will enhance the teaching/learning process of the child and not the coordination of the child's inspiration.
A nurse is administering medication to a client via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation? a. Remove the tube and replace it with a new tube. b. Use a syringe to plunge the tube to try to dislodge the medication. c. Call the physician before instituting any corrective interventions. d. Wait the prescribed amount of time and attempt to administer the medication again before calling the physician.
b. Use a syringe to plunge the tube to try to dislodge the medication. When medication becomes clogged in the tube, the nurse should attach a 10-mL syringe onto the end of the tube, pull back, and then lightly apply pressure to the plunger in a repetitive motion. This may dislodge the medication. If the medication does not move through the tube, the physician should be notified. The nurse should not remove the tube nor wait for a prescribed amount of time to attempt to readminister the medication.
A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client: a. takes rapid, shallow breaths until the medication is complete. b. breathes through his or her mouth until all the medication has been inhaled. c. coughs intermittently while the medication is being administered. d. rinses his or her mouth with water before the medication is administered.
b. breathes through his or her mouth until all the medication has been inhaled. The client should breathe through his or her mouth rather than through the nose. It is not necessary to rinse before administration or to cough during administration. Deep breathing is preferable to shallow breathing because this improves absorption.
A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique? a. intravenous b. intramuscular c. intradermal d. subcutaneous
b. intramuscular When administering intramuscular injections, nurses may administer drugs that may be irritating to the upper levels of tissue by the Z-track technique. Clients report slightly less pain during (and the day after) a Z-track injection compared with the usual intramuscular injection technique. The Z-track technique is not suitable for intravenous injections, as they are administered into the veins, nor is it used for intradermal or subcutaneous injections.
A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication? a. read and compare labels on the medication with the medical record b. review the client's medication, allergy, and medical history c. administer medication within 30 to 60 minutes of the scheduled time d. allow sufficient time to prepare the medication with minimal distraction
b. review the client's medication, allergy, and medical history To avoid any potential complications, the nurse should review the client's medication, allergy, and medical history. The nurse should read and compare the label on the medication with the medical record at least 3 times (before, during, and after preparing the medication) to ensure that the right medication is given at the right time by the right route. Administering the medication within 30 to 60 minutes of the scheduled time demonstrates timely administration and compliance with the medical order. Allowing sufficient time to prepare the medication with minimal distraction promotes the safe preparation of medications.
A client's eMAR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? a. Recognize that it is not safe to mix two medications in one syringe. b. Page the health care provider to determine whether the drugs can be mixed. c. Determine the compatibility of the two drugs by consulting clinical resources. d. Collaborate with the pharmacy to have one of the times changed.
c. Determine the compatibility of the two drugs by consulting clinical resources. The nurse must determine the compatibility of the two drugs; some drugs can be safely combined in a single syringe. However, this is not determined by paging the health care provider. There is no need to change the times of administration.
While receiving a medication IV piggyback, the client reports discomfort at the IV site. Upon assessment, the site is cool to the touch and slightly swollen. What is the best action by the nurse? a. Apply a cool, moist compress for 20 minutes. b. Slow the rate of infusion until client reports relief. c. Discontinue the IV site and restart IV in a new location. d. Monitor the site closely for any signs of complications.
c. Discontinue the IV site and restart IV in a new location. The assessment reveals the IV has infiltrated. The nurse should stop the IV fluid and remove the IV from the extremity, then restart the IV in a different location. Applying a cool, moist compress or slowing the rate will not address the problem of the IV fluid going into the surrounding tissue instead of the vein. Monitoring the site is not appropriate, because there is already a complication present that requires action by the nurse.
The nurse is assessing a client with diabetes who has poor vision. Which feature of the insulin pen makes it beneficial for this client? a. The insulin pen is easily transported on the client. b. It is easier to learn how to use an insulin pen than a syringe and vial. c. Each unit of insulin is accompanied by a clicking sound in the pen. d. With an insulin pen, a large variety of insulin types are available.
c. Each unit of insulin is accompanied by a clicking sound in the pen. Each unit of insulin is accompanied by a clicking sound in the pen. This is a beneficial feature for the client who has poor vision, as the sound will alert the client to count when selecting the prescribed dose. Being easily transported, being easier to learn, and having a variety of types available are all advantages for using insulin pens, but they do speak specifically to this client.
When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation? a. Pull out and discard the needle. b. Discard the equipment and start the procedure from the beginning. c. Engage safety shield on needle guard and discard needle appropriately. d. Document the incident and inform the primary care provider.
c. Engage safety shield on needle guard and discard needle appropriately. The needle needs to be disposed of properly after engaging the safety guard because the needle cannot be reinserted due to contamination. A new needle can be attached to the syringe and the remainder of the medication administered after cleansing the site again. The incident does warrant notifying the primary care provider.
A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case? a. Inform the physician about the client's absence. b. Leave the medication on the client's bedside table. c. Return the medication to the medication cart or medication room. d. Inform the head nurse about the client's absence.
c. Return the medication to the medication cart or medication room. If the client is not present at the time when the medication needs to be administered, the nurse should return the medication to the medication cart or medication room. Leaving medications on the client's bedside table may result in their loss or accidental ingestion by someone else. The nurse need not inform the physician or the head nurse about the client's absence.
Which parts of the syringe and needle must be kept sterile when preparing and administering an injection? Select all that apply. a. The outside of the cap b. The outside of the barrel c. The needle hub d. The needle e. Inside the barrel
c. The needle hub d. The needle e. Inside the barrel Techniques of surgical asepsis must be strictly followed to avoid risk of infection. The parts of the syringe and needle that must be kept sterile are the inside of the barrel, the part of the plunger that enters the barrel, the tip of the barrel, and the needle (including the hub). The outside of the cap and barrel do not need to be kept sterile.
The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which would help maximize drug absorption in this client? a. turbo-inhaler b. metered-dose inhaler c. spacer d. nasal drops
c. spacer A spacer would help maximize the absorption of the drug in a client who is having problems coordinating his breathing with the inhaler use. A spacer provides a reservoir for the aerosol medication. As the client takes additional breaths, he continues to inhale the medication held in the reservoir. This tends to maximize the drug's absorption, because it prevents drug loss. A metered-dose inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed. A turbo-inhaler is a propeller-driven device that spins and suspends a finely powdered medication. Nasal drops are liquid medication sprayed or dropped into the client's nose. These, however, would not help in maximizing the absorption of the medication.
The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone? a. No extra documentation is necessary. b. Have another nurse cosign the order input. c. Tell the provider to sign the order as soon as possible. d. Record "T.O." at the end of the order.
d. Record "T.O." at the end of the order. Recording "T.O." at the end of the order indicates that this was a telephone order. Another nurse should not cosign the order. Reminding the provider to sign the order as soon as possible is helpful, but it does not indicate that this was a telephone order.
Which is a recommended guideline for the nurse who is administering a piggyback intermittent intravenous infusion of medication? a. Place the minibag lower than the primary solution container. b. Ask the health care provider to specify the correct infusion rate. c. Using clean technique, remove the tubing spike cap and the cap on the port of the medication container. d. Attach infusion tubing to the minibag by inserting the tubing spike into the port with a firm push and twisting motion.
d. Attach infusion tubing to the minibag by inserting the tubing spike into the port with a firm push and twisting motion. Attach the infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion, taking care to avoid contaminating either end. The IV piggyback delivery system requires the intermittent or additive solution to be placed higher than the primary solution container. The nurse is responsible for calculating and regulating the infusion with an infusion pump. Using aseptic technique, remove the tubing spike cap and the cap on the port of the medication container.
The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action? a. Administer the drug as ordered. b. Ask another nurse to verify the order. c. Assume that the provider meant to order buspirone. d. Contact the health care provider for order clarification.
d. Contact the health care provider for order clarification. The nurse should contact the health care provider to verify the order. Bupropion and buspirone are drugs that have look-alike and sound-alike properties but are different in indication. The nurse should not automatically administer the drug, nor ask another nurse to verify an order, nor assume what is meant by an order.
The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse? a. Call the physician to request oral antibiotics. b. Flush the lock with heparin solution. c. Administer the prescribed antibiotics as prescribed. d. Insert a new IV medication lock and remove the old one.
d. Insert a new IV medication lock and remove the old one. The nurse is to flush the medication IV lock every 8 to 12 hours, or depending on the facility policy. When flushing the IV lock, the nurse verifies the patency of the lock by aspirating blood return and the lock should flush without resistance. If the nurse is unable to flush without resistance, if there is leaking from the site during flushing, or if patency cannot be verified, the nurse should remove the IV lock and insert a new IV lock. If the nurse has resistance with flushing with saline, flushing with heparin would not be an appropriate option. The nurse should not administer the antibiotic if the IV lock is resistant during flushing. Calling the physician to change the order is not appropriate.
A nurse is preparing to administer a scheduled dose of enteric-coated ASA to a client who has a history of angina. When preparing the medication, the nurse is careful to check the five rights of medication administration. The five rights include which of the following? a. Right setting b. Right reason c. Right documentation d. Right time
d. Right time The five rights consist of the right client, right drug, right dose, right route and right time. It is prudent to be aware of the right documentation, setting and reason, but these are not considered to be among the five rights.
When administering heparin subcutaneously, the nurse should: a. aspirate after the injection. b. aspirate before the injection. c. vigorously massage the site. d. never aspirate.
d. never aspirate. When administering heparin subcutaneously, never aspirate before administration.
The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity? a. placing the secondary and primary infusion at equal height b. placing the primary solution higher than the secondary solution c. stopping the primary solution until the secondary infusion is completed d. placing the secondary infusion higher than the primary solution
d. placing the secondary infusion higher than the primary solution The nurse should place the secondary infusion higher than the primary infusion. This will allow the secondary infusion to infuse first. When completed, the primary infusion will continue to infuse. The other options are not correct.
The primary reason for the Controlled Substances Act is: a. to regulate the purchase of antibiotics. b. to regulate the purchase of narcotics. c. to prevent overuse of antibiotics. d. to prevent drug use and dependence.
d. to prevent drug use and dependence. The primary reason for the Controlled Substances Act is to prevent drug use and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug use laws.
