NCLEX Taylor Nursing Chapter 28: Medications

A nurse is administering intramuscular injections to patients on a hospital ward. What needle sizes has the nurse used correctly? (Select all that apply.) a. 5/8-inch needle for the vastus lateralis site b. 5/8-inch needle for an adult in the ventro- gluteal site c. 1 Vi-inch needle for a child in the deltoid site d. 1 %-inch needle for an adult in the deltoid site e. 5/8-inch needle for a child in the deltoid site f. 5/8-inch needle for an adult in the ventro-gluteal site

a, c, d, e

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 head nurse about the client's absence. b) Inform the physician about the client's absence. c) Return the medication to the medication cart or medication room. d) Leave the medication on the client's bedside table.

c) Return the medication to the medication cart or medication room.

Which action describes buccal medication administration? a) placing a medication through a nasogastric tube b) placing a medication, which is designed to be absorbed through the skin for systemic effects, on the skin c) placing a medication under the tongue and allowing it to dissolve d) placing a medication underneath the upper lip or in the side of the mouth

d) placing a medication underneath the upper lip or in the side of the mouth

When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug? a) taking the medication on an empty stomach b) performing physical activities c) talking when taking the medication d) swallowing the medication

d) swallowing the medication

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) Allow sufficient time to prepare the medication with minimal distraction. b) Administer medication within 30 to 60 minutes of the scheduled time. c) Review the client's medication, allergy, and medical history. d) Read and compare labels on the medication with the medical record.

c) Review the client's medication, allergy, and medical history.

Regarding medication administration, what must occur at the change of shifts? a) Only the LPNs on the division count medications. b) The client's medications must be drawn up. c) The narcotics for the division are counted. d) The medications for the division are counted.

c) The narcotics for the division are counted.

A nurse flushes an intravenous lock before and after administering a medication. What is the rationale for this step? a) to dilute the infusion and maintain homeostasis b) to keep the inside of the needle or catheter sterile c) to facilitate client comfort and decrease anxiety d) to clear medication and prevent clot formation

d) to clear medication and prevent clot formation

A nurse is administering an injection of insulin to a 5-year-old who has juvenile diabetes. Which statement by the nurse would take into consideration this child's developmental level? a. "Don't worry, this won't hurt a bit." b. "If you are brave and don't cry, I will give you a sticker." c. "Try not to move, or this will hurt more." d. "You will just feel a little pinch."

d. "You will just feel a little pinch."

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? A. Asbestos exposure B. Exposure to uranium C. Chronic interstitial fibrosis D. History of cigarette smoking E. Geographic area in which he was born

A,B,D. Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk, but not necessarily where the patient was born.

To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? A. Maintain adequate fluid intake. B. Splint the chest when coughing. C. Maintain a 30-degree elevation. D. Maintain a semi-Fowler's position. E. Instruct patient to cough at end of exhalation.*

A,B,E. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which risk factors (select all that apply)? A. Obesity B. Pneumonia C. Malignancy D. Cigarette smoking E. Prolonged air travel

A,C,D,E. An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, surgery within the last 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions

A. Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths/minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

When the patient with a persisting cough is diagnosed with pertussis (instead of acute bronchitis), the nurse knows that treatment will include which type of medication? A. Antibiotic B. Corticosteroid C. Bronchodilator D. Cough suppressant

A. Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

During discharge teaching for a 65-year-old patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? A. Pneumococcal B. Staphylococcus aureus C. Haemophilus influenzae D. Bacille-Calmette-Guérin (BCG)

A. The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis (TB) is prevalent.

Which physical assessment finding in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A. Basilar crackles B. Respiratory rate of 28 C. Oxygen saturation of 85% D. Presence of greenish sputum

A. The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem, but do not definitely support the nursing diagnosis of ineffective airway clearance.

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of A. cough reflex. B. mucociliary clearance. C. reflex bronchoconstriction. D. ability to filter particles from the air.

B. Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? A. Orthostatic blood pressures B. Sputum culture and sensitivity C. Pulmonary function evaluation D. Serum laboratory studies ordered for AM

B. The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

Which clinical manifestation should the nurse expect to find during assessment of a patient admitted with pneumonia? A. Hyperresonance on percussion B. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation D. Fine crackles in all lobes on auscultation

C. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing intervention is most appropriate based upon these findings? A. Continue with ambulation since this is a normal response to activity. B. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

C. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

When the patient is diagnosed with a lung abscess, what should the nurse teach the patient? A. Lobectomy surgery is usually needed to drain the abscess. B. IV antibiotic therapy will be used for a prolonged period of time. C. Oral antibiotics will be used when the patient and x-ray shows evidence of improvement. D. No further culture and sensitivity tests are needed if the patient takes the medication as ordered.

C. IV antibiotics are used until the patient and x-ray show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

C. If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

The patient with HIV has been diagnosed with Candida albicans, an opportunistic infection. The nurse knows the patient needs more teaching when she says, A. "I will be given amphotericin B to treat the fungus." B. "I got this fungus because I am immunocompromised." C. "I need to be isolated from my family and friends so they won't get it." D. "The effectiveness of my therapy can be monitored with fungal serology titers."

C. The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

What nursing intervention is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on right side B. Maintaining adequate fluid intake C. Positioning patient with "good lung" down D. Performing postural drainage every 4 hours

C. Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able. B. Administer cough suppressant q4hr. C. Teach patient to splint the affected area. D. Increase fluid intake to 3 L/day if tolerated.

D. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing intervention is most appropriate during admission of this patient? A. Perform a comprehensive health history with the patient to review prior respiratory problems. B. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.

The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient? A. Pulmonary infarction B. Pulmonary hypertension C. Cytomegalovirus (CMV) D. Bronchiolitis obliterans (BOS)

D. Bronchiolitis obliterans (BOS) is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? A. The patient has lung cancer. B. The incision will be medial sternal or lateral. C. Chest tubes will not be needed postoperatively. D. Less discomfort and faster return to normal activity

D. The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep-breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D. The follow-up chest x-ray will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

What are components of a medication order? (Select all that apply.) a. The full name of the patient b. The date and sometimes the time when the order is written c. Preferably the brand name of the drug to be administered d. The dosage of the drug, stated in either the apothecary or metric system e. The route by which the drug is to be administered, only if there is more than one route possible f. The signature of the nurse carrying out the order

a, b, d

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4° F, blood pressure 130/88, respirations 36/minute, and oxygen saturation 91% on room air. What action should the nurse take first? A. Notify the physician. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed as tolerated and apply oxygen.

D. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

A nurse is reconstituting powdered medication in a vial. Which action is a recommended step in this process? a) The nurse draws up the proper amount of powered medication into the syringe. b) The nurse inserts the needle through the rubber stopper of the diluent vial. c) The nurse gently agitates the powdered medication vial to mix the powder and diluent completely. d) The nurse draws up the prescribed amount of medication while holding the syringe horizontally at eye level.

c) The nurse gently agitates the powdered medication vial to mix the powder and diluent completely.

A medication order reads: "K-Dur, 20 mEq po b.i.d." When and how does the nurse correctly give this drug? a) Daily at bedtime by subcutaneous route b) Every other day by mouth c) Twice a day by the oral route d) Once a week by transdermal patch

c) Twice a day by the oral route

Which actions would the nurse take when instilling eyedrops correctly? (Select all that apply.) a. Wash hands and put on gloves. b. Clean the eyelids and eyelashes of any drainage with cotton balls soaked in clean water. c. Tilt the patient's head back slightly if sitting or place the head on a pillow if lying down. d. Have the patient look up and focus on something on the ceiling. e. Place the thumb near the margin of the lower eyelid and exert pressure upward over the bony prominence of the cheek. f. Squeeze the container and allow the prescribed number of drops to fall into the cornea.

a, c, d

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection? a) 1 mL b) 3 mL c) 0.05 mL d) 0.01 mL

a) 1 mL

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 1 p.m. 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) 3 p.m. b) 12 noon c) Wait until day 5 of treatment. d) 8 p.m.

a) 3 p.m. Peak levels are drawn shortly after the drug is administered. The best choice is 3 p.m. because it closely follows the time of infusion, which is when the drug concentration would be highest.

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies his identity by: a) Asking the patient his name b) Reading the patient's name on the sign over the bed c) Asking the patient's roommate to verify his name d) Asking, "Are you Mr. Brown?"

a) Asking the patient his name

A nurse is administering an oral medication to a patient via a gastric tube. The nurse observes the medication enter the tube, and then the tube becomes clogged. What would be the appropriate initial action of the nurse in this situation? a) Attempt to dislodge the medication with a 10-mL syringe. b) Notify the primary care provider. c) Remove the tube and replace it with another tube. d) Flush the tube with 60 mL of water.

a) Attempt to dislodge the medication with a 10-mL syringe.

The nurse is reviewing a client's newly written medication order and is unable to read the prescriber's handwriting. Which action by the nurse is most appropriate? a) Contact the prescriber to clarify the order. b) Send the order to the pharmacy for accurate interpretation. c) Confer with another nurse who is more familiar with the prescriber's handwriting. d) Disregard the order until the prescriber returns to the unit.

a) Contact the prescriber to clarify the order.

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. a) Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. b) Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. c) Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. d) During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. e) The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. f) Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

a) Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. d) During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. f) Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which action should the nurse perform to prevent gastric reflux? a) Help the client into a Fowler's position. b) Check for drug allergies in the client's history. c) Administer the medication over several minutes. d) Add diluted medication to the syringe.

a) Help the client into a Fowler's position.

Which actions would the nurse perform when administering a subcutaneous injection correctly? Select all that apply. a) Inject the needle quickly at an angle of 45 to 90 degrees. b) After removing the needle, do not massage the area to prevent hematoma formation. c) If blood appears when aspirating, withdraw the needle and reinject it at another site. d) Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. e) Remove the needle cap with the dominant hand, pulling it straight off. f) If using the outer aspect of the upper arm, place the client's arm over the chest with the outer area exposed.

a) Inject the needle quickly at an angle of 45 to 90 degrees. b) After removing the needle, do not massage the area to prevent hematoma formation. d) Grasp and bunch the area surrounding the injection site or spread the skin taut at the site.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler? a) It is a canister that contains pressurized medication. b) It has propellers that get activated during inhalation. c) It is a battery-operated device that spins. d) It suspends finely powdered medication.

a) It is a canister that contains pressurized medication.

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. a) Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b) Some people experience the same response with a placebo as with the active drug used in studies. c) People with liver disease metabolize drugs more quickly than people with normal liver functioning. d) A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. e) Oral medications should not be given with food as the food may delay the absorption of the medications. f) Circadian rhythms and cycles may influence drug action.

a) Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. b) Some people experience the same response with a placebo as with the active drug used in studies. d) A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. f) Circadian rhythms and cycles may influence drug action.

A nurse is teaching an adolescent patient how to use a meter-dosed inhaler to control his asthma. What are appropriate guidelines for this procedure? Select all that apply. a) Remove the mouthpiece cover and shake the inhaler well. b) Take shallow breaths when breathing through the spacer. c) Depress the canister releasing one puff into the spacer and inhale slowly and deeply. d) After inhaling, exhale quickly through pursed lips. e) Wait 1 to 5 minutes as prescribed before administering the next puff. e) Gargle and rinse with salt water after using the MDI.

a) Remove the mouthpiece cover and shake the inhaler well. c) Depress the canister releasing one puff into the spacer and inhale slowly and deeply. e) Wait 1 to 5 minutes as prescribed before administering the next puff.

A home care nurse is educating a client with diabetes on how to self-administer insulin. Which teaching point would the nurse include in the education plan? a) Rotate the injection site. b) Reuse syringes and needles up to three times. c) Store needles and syringes in a glass container. d) Use the same site on the body for each injection.

a) Rotate the injection site.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? a) The client has anti-A antibodies. b) The client is a universal donor. c) The client has anti-B antibodies. d) The client has both anti-A and anti-B antibodies.

a) The client has anti-A antibodies. Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client? a) Vastus lateralis site b) Ventrogluteal site c) Dorsogluteal site d) Deltoid site

a) Vastus lateralis site

The nurse is administering medication to a patient through a drug-infusion lock using the saline flush. During the process, the patient complains of pain at the site. Which interventions are appropriate in this situation? (Select all that apply.) a. Stop the medication and assess the site for signs of infiltration and phlebitis. b. Flush the medication lock with normal saline again to recheck patency. c. If site is within normal limits, resume medication administration at a slower rate. d. Immediately stop the medication, remove medication lock, and restart at new site. e. Notify the primary care provider that the site has been infiltrated. f. Finish administering medication and then change the medication lock.

a, b, c

An oral medication has been ordered for a patient 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 Mr. Moran 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 is administering a subcutaneous injection of insulin to a patient. Which action would the nurse take after choosing the appropriate administration site? a. Identify the appropriate landmarks for the site chosen. b. Cleanse the area around the injection site with alcohol. c. Use a firm, back and forth motion to cleanse the site. d. Remove the needle cap with the dominant hand pulling it straight off.

a. Identify the appropriate landmarks for the site chosen.

A nurse is ordered to administer epinephrine to a child who was stung by a bee and is allergic to insect bites. Which means of drug administration would the nurse use to achieve rapid absorption and quicker results in this emergency situation? a. Injection b. Oral c. Patch d. Inhalation

a. Injection

A home care nurse is teaching a patient with diabetes how to self-administer insulin. Which teaching point would the nurse include in the teaching plan? a. Use the same area of the body at the same time every day. b. Use the same site on the body for each injection. c. Reuse syringes and needles up to three times. d. Store needles and syringes in a glass container.

a. Use the same area of the body at the same time every day.

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) 2"; 18 gauge b) 1"; 22 gauge c) 5/8"; 24 gauge d) 1½"; 18 gauge

b) 1"; 22 gauge IM injections using the deltoid site require a 20- to 25-gauge needle that is between 1" and 1½" in length.

Ms. Hall has an order for hydromorphone (Dilaudid), 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to Dilaudid. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? a) Administer the medication; the doctor is responsible for medication administration. b) Call Dr. Long and ask that she change the medication. d) Ask the supervisor to administer the medication. e) Ask the pharmacist to provide a medication to take the place of Dilaudid.

b) Call Dr. Long and ask that she change the medication.

A physician orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? a) A single dose during the postoperative period b) Doses administered as needed for pain relief c) One dose administered immediately d) Doses routinely administered as a standing order

b) Doses administered as needed for pain relief

A nurse is caring for a client who has a PICC line. Which nursing action is recommended? a) Use clean technique when changing dressing. b) Flush using normal saline and/or heparin solution according to facility policy. c) Keep external portion of catheter coiled on top of dressing. d) Change catheter caps every 10 days or as per facility policy.

b) Flush using normal saline and/or heparin solution according to facility policy.

Which situation accurately describes a recommended guideline when administering oral medications to clients? a) If a pill is dropped, it should be briefly immersed in saline to remove any dirt or germs. b) If a child refuses to take medication, the medication can be crushed and added to a small amount of food. c) Assume that the client is the authority on whether or not the medication was swallowed. d) If a client vomits immediately after receiving oral medications, re-administer the medication.

b) If a child refuses to take medication, the medication can be crushed and added to a small amount of food.

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? a) Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. b) Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. c) Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. d) Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

b) Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin.

Which "rights" are included in the "six rights for medication administration"? Select all that apply. a) Right room b) Right route c) Right time d) Right diagnosis e) Right dose f) Right medication

b) Right route c) Right time e) Right dose f) Right medication

A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations? a) When the drug needs to be administered only once b) When the client has disorders that affect the absorption of medications c) When the client wants to avoid the discomfort of an intradermal injection d) When the drug needs to act on the client very slowly

b) When the client has disorders that affect the absorption of medications

A nurse is using an 18-gauge needle to administer a medication to a client. The nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which feature? a) greater length b) larger diameter c) smaller diameter d) shorter length

b) larger diameter

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 supply that remains on the nursing unit for use in emergency b) self-contained packets that hold one tablet or capsule for individual clients c) a container with enough prescribed medications for several days for a client d) systems that contain frequently used medication for that unit

b) self-contained packets that hold one tablet or capsule for individual clients

A nurse who is administering a piggyback intermittent intravenous infusion of medication to a patient observes that there is a cloudy, white substance forming in the IV tubing. What actions should the nurse take in this situation? (Select all that apply.) a. Assess the IV site for signs of infiltration or phlebitis. b. Stop the IV from flowing and stop administering the medication. c. Prime the secondary tubing by "backfilling" it. d. Clamp the IV at the site nearest to the patient. e. Replace tubing on primary and secondary infusions. f. Check literature regarding incompatibilities of medications after administering.

b, d, e

The nurse is teaching a patient how to use an insulin pen. Which steps reflect recommended procedure? (Select all that apply.) a. After administering injection, keep button depressed; count to 3 before removal. b. Hold the pen upright and tap to force any air bubbles to the top. c. Check that dose selector is at 2 before dialing units of insulin for the dose. d. After administering the injection, push the button on the pen half-way in. e. Dial the dose selector to 2 units to perform an "air shot" to get rid of bubbles f. Clean injection site and administer injection by holding pen like a dart.

b, e, f

Which actions would a nurse perform when instilling eardrops correctly? (Select all that apply.) a. Make sure the solution to be instilled is at room temperature. b. Clean the external ear with cotton balls moistened with normal saline solution. c. Place the patient on the affected side in bed. d. Draw up the amount of solution needed in the dropper and return any excess medication to the stock bottle. e. Straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back in an adult and down and back in an infant or child under 3 years. f. Hold the dropper in the ear with its tip above the auditory canal.

b, e, f

A patient has an order for Chloromycetin, 500 mg every 6 hours. The drug comes in 250 mg capsules. What would the nurse administer? a. 1 tab b. 2 tabs c. 3 tabs d. 4 tabs

b. 2 tabs

A physician prescribes a PRN order for a post- surgical patient. When would the nurse administer the medication? a. Every hour b. As needed c. One time only d. Immediately

b. As needed

A nurse is administering an anti-hypertensive drug to a hospitalized patient. What action should the nurse take to identify the patient prior to administration? a. Call the patient by name. b. Check the patient's ID bracelet. c. Check the patient's record. d. Check the patient's name with family or significant others.

b. Check the patient's ID bracelet.

A nurse is administering a hepatitis B shot to an adult patient. 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

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.

While injecting a needle into a patient for an intramuscular injection, the nurse hits the patient's bone. What would be the appropriate initial response of the nurse to this situation? a. Remove the needle and have another nurse stay with the patient while informing the primary care provider. b. Withdraw the needle, apply a new needle to syringe, and administer the injection in an alternate site. c. Document the incident according to facility policy and then remove the needle and syringe and discard it. d. Remove the needle and discard the needle and syringe; call the primary care provider.

b. Withdraw the needle, apply a new needle to syringe, and administer the injection in an alternate site.

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 which have 30 g in 45 mL. How many milliliters is the nurse going to administer every 6 hours to the client? a) 22.5 mL b) 15 mL c) 30 mL d) 67.5 mL

c) 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

When educating an older adult client about the administration of medication during discharge, the nurse notes that the client is having difficulty comprehending the instruction. What intervention should the nurse follow in this case to ensure the client's safety? a) Ask the client's physician to provide instruction. b) Write discharge instructions on the medication containers. c) Ask a second nurse to repeat the instruction. d) Involve a second responsible person in the instruction.

c) Ask a second nurse to repeat the instruction.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? a) Instill the medication in the opposite ear if prescribed. b) Place a cotton ball in the ear to absorb excess medication. c) Ask the client to maintain the position for some time. d) Briefly postpone the application in the second ear.

c) Ask the client to maintain the position for some time.

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? a) Readminister the medication and notify the primary care provider. b) Readminister the pill in a liquid form if possible. c) Assess the vomit, looking for the pill. d) Notify the primary care provider.

c) Assess the vomit, looking for the pill.

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) Electronic infusion device b) Secondary administration c) Bolus administration d) Continuous administration

c) Bolus administration

The nurse is administering a medication to a patient via a nasogastric tube. Which are accurate guidelines related to this procedure? Select all that apply. a) Crush the enteric-coated pill for mixing in a liquid. b) Flush open the tube with 60 mL of very warm water. c) Check for proper placement of the nasogastric tube. d) Give each medication separately and flush with water between each drug. e) Lower the head of the bed to prevent reflux. f) Adjust the amount of water used if patient's fluid intake is restricted.

c) Check for proper placement of the nasogastric tube. d) Give each medication separately and flush with water between each drug. f) Adjust the amount of water used if patient's fluid intake is restricted.

A nurse discovers that she made a medication error. What should be the nurse's first response? a) Record the error on the medication sheet. b) Notify the physician regarding course of action. c) Check the patient's condition to note any possible effect of the error. d) Complete an incident report, explaining how the mistake was made.

c) Check the patient's condition to note any possible effect of the error.

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? a) Aspirate before giving and gently massage after the injection. b) Do not aspirate; massage the site for 1 minute. c) Do not aspirate before or massage after the injection. d) Massage the site of the injection; aspiration is not necessary but will do no harm.

c) Do not aspirate before or massage after the injection.

A nurse is caring for a client on IV therapy. The IV tubing has a volume-control set. Which of the following is a function of the volume-control set? a) It is used when IV medications are irritating to peripheral veins. b) It is used to administer medication in a large volume of blood. c) It is used to administer small volumes of IV medication. d) It is used to administer medication continuously.

c) It is used to administer small volumes of IV medication.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do? a) Have another nurse guard the preparations. b) Put the medications back in the containers. c) Lock the medications in a cart and finish them upon return. d) Have another nurse finish preparing and administering the medications.

c) Lock the medications in a cart and finish them upon return.

A nurse is administering an intramuscular injection to a client using the Z-track method. Which action should the nurse perform to prevent leaking and ensure sealing of medication in the subcutaneous and dermal layers of tissue? a) Apply pressure and massage the site immediately. b) Insert the needle at a 90-degree angle into the tissue. c) Withdraw the needle and release taut skin immediately after injection. d) Manipulate the plunger with the help of the thumb.

c) Withdraw the needle and release taut skin immediately after injection. Withdrawing the needle and immediately releasing the taut skin creates a diagonal path that prevents the medication from leaking into the subcutaneous and dermal layers of tissue. Manipulating the plunger with the help of the thumb avoids releasing the tissue held taut by the nondominant hand. Applying pressure, but not massaging the site, ensures that the medication remains sealed. Inserting the needle at a 90-degree angle directs the tip of the needle within the muscle.

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 drug abuse. d) to prevent overuse of antibiotics.

c) to prevent drug abuse.

Which actions would the nurse perform when administering a subcutaneous injection correctly? (Select all that apply.) a. If using the outer aspect of the upper arm, place the patient's arm over the chest with the outer area exposed. b. Remove the needle cap with the dominant hand, pulling it straight off. c. Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. d. Inject the needle quickly at an angle of 45 to 90 degrees. e. If blood appears when aspirating, withdraw the needle and reinject it at another site. f. After removing the needle, do not massage the area to prevent hematoma formation.

c, d, f

A nurse administers a dose of gentamicin, and the patient has an immediate reaction of hypotension, bronchospasms, and rapid, thready pulse. What is the next appropriate action of the nurse? a. Administer antibiotic, antihistamines, and Isuprel b. Administer bronchodilators, antihistamines, and vasodilators c. Administer epinephrine, antihistamines, and bronchodilators d. Administer antihistamines, vasodilators, and bronchoconstrictors

c. Administer epinephrine, antihistamines, and bronchodilators

When administering a subcutaneous injection to a patient, 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 nurse is working the night shift in the ER when an ambulance arrives carrying a man s/p motor vehicle accident (MVA). His initial BP is 100/56 and the nurse notes that he is bleeding heavily from a laceration on the forehead. Fifteen minutes later, the nurse reassesses the client and finds that his BP is 95/58. What IV fluid would the nurse expect to be ordered? a) 3% NS b) 0.45% NS c) D5 ¼ NS d) 0.9% NS

d) 0.9% NS

A nurse needs to administer a subcutaneous heparin injection to a client. Which injection site is most suitable for heparin? a) Back b) Upper chest c) Forearm d) Abdomen

d) Abdomen

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss? a) When looking at a needle package, the first number is the length in inches and the second number is the gauge or diameter of the needle. b) When giving an injection, the amount of the medication directs the choice of gauge. c) The size of the syringe is directed by the viscosity of the medication to be given. d) As the gauge number becomes larger, the size of the needle becomes smaller.

d) As the gauge number becomes larger, the size of the needle becomes smaller.

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) Cross-reference the MAR with the client's medical record. b) Enlist the help of a colleague who is familiar with the client. c) Ask the client his name prior to giving the drug. d) Check the client's identification band.

d) Check the client's identification band.

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. Which nursing action is correct? a) Give all the medication in the cartridge because it expanded when it was mixed. b) Call the pharmacy and request the proper dose. c) Refuse to give the medication. d) Dispose of 0.2 mL correctly before administering the drug.

d) Dispose of 0.2 mL correctly before administering the drug.

Which is a drug class that strengthens cardiac contraction? a) Diuretics b) Anticoagulants c) Antiarrhythmics d) Inotropes

d) Inotropes

Which factor is associated with rapid absorption of a drug? a) Decreased blood flow b) Oral route of administration c) Basic environment in the stomach d) Intravenous route of administration

d) Intravenous route of administration

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 of the following would help maximize drug absorption in this client? a) Nasal drops b) Turbo-inhaler c) Metered-dose inhaler d) Spacer

d) Spacer

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which describes the mechanism of a metered-dose inhaler? a) a propeller-driven device that spins and suspends a finely powdered medication b) a device that forces medication through a narrow channel with the help of inert gas c) a device that forces liquid drug through a narrow channel using pressurized air d) a canister containing medication that is released when the container is compressed

d) a canister containing medication that is released when the container is compressed

To which of the following clients would the nurse be most likely to administer a p.r.n. medication? a) a client who requires daily medication to control hypertension b) a client who is experiencing severe and unprecedented chest pain c) a client whose asthma is treated with inhaled corticosteroids d) a client who is reporting pain near her surgical site

d) a client who is reporting pain near her surgical site

A nurse is administering medication to a 78-year-old female patient who experienced symptoms of stroke. When administering the medication prescribed for her, the nurse should be aware that this patient has an increased possibility of drug toxicity due to which of the following age-related factors? a. Decreased adipose tissue and increased total body fluid in proportion to total body mass b. Increased number of protein-binding sites c. Increased kidney function, resulting in excessive filtration and excretion d. Decline in liver function and production of enzymes needed for drug metabolism

d. Decline in liver function and production of enzymes needed for drug metabolism

What action should the nurse take when giving an intramuscular injection using the Z-track method? a. Use a needle at least 1 inch long. b. Apply pressure to the injection site. c. Inject the medication quickly, and steadily withdraw the needle. d. Do not massage the site because it may cause irritation.

d. Do not massage the site because it may cause irritation.

A nurse is administering an intradermal injection to a patient for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's best action in this situation? a. Choose another site and re-inject the medication. b. Prepare another syringe and administer it to the patient at the same site. c. Document the administration as correctly administered. d. Document the administration and inform the primary care provider.

d. Document the administration and inform the primary care provider.

A nurse preparing medication for a patient is called away to an emergency. What should the nurse do? a. Have another nurse guard the preparations. b. Put the medications back in the containers. c. Have another nurse finish preparing and administering the medications. d. Lock the medications in a room and finish them upon return.

d. Lock the medications in a room and finish them upon return.