NUR 231; PREP U UNIT 2

Drugs known to cause birth defects are called: pregnancy sensitivity. umbilical cross. teratogenic. nosocomial.

teratogenic

The nurse is preparing to administer an enteric-coated aspirin to a client. The client states, "I cannot swallow that so you will have to crush it and put it in applesauce for me as the other nurse does." Which is an appropriate reply from the nurse? "The nurse should not have crushed this medication. It could have caused an allergic reaction." "I can crush the medication but will not be able to mix it in the applesauce, because it will limit the effectiveness." "Crushing the medication may cause the medication to irritate the stomach, so it must be swallowed whole." "I will ask the health care provider to cancel the prescription for aspirin since you are unable to take it."

"Crushing the medication may cause the medication to irritate the stomach, so it must be swallowed whole."

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? "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes." "As a registered nurse you will not have to perform skills like bathing and administering medications unless you want to." "You will be able to perform all the skills the health care provider allows you to perform when you become a nurse." "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."

"Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes."

The nurse is teaching a client with heart failure about taking digoxin safely. Which statement by the client indicates teaching was effective? "I will decrease the amount of potassium in my diet." "If my pulse is higher than 100 beats/min, I will hold the dose." "I will call the health care provider if I develop dizziness, blurred vision, or nausea." "I will store this medication in the refrigerator."

"I will call the health care provider if I develop dizziness, blurred vision, or nausea."

Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response? "I will log in so that you can proceed with medication delivery." "I am giving you my password so you can log in." "I will get the hospital's information system's phone number for you." "I can log in and give the medications for you."

"I will get the hospital's information system's phone number for you."

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply. "It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Try to do everything by yourself at home to build your strength back." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal."

"It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal."

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "You will receive medication through this device." "Drainage will occur by gravity and capillary action." "It provides a way to remove drainage and blood from the surgical wound." "The bulb-like system will stay in place permanently after your mastectomy."

"It provides a way to remove drainage and blood from the surgical wound."

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response? "This is to decrease the amount of drug that you receive." "Medication stays in the chamber so you can continue to inhale it." "You will receive the medication faster as it goes through this device." "It makes the inhaler easier to hold in case you have arthritis."

"Medication stays in the chamber so you can continue to inhale it."

The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective? "Reconstitution is the process of adding liquid, known as diluent, to a powdered substance." "Reconstitution is a sealed glass cylinder of parenteral medication with an attached needle." "Reconstitution is a glass or plastic container of parental medication with a self-sealing rubber stopper." "Reconstitution is a sealed glass drug container that must be broken to withdraw the medication."

"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction."

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

Which statement by a client indicates to the nurse that teaching was effective regarding the different parts of a syringe? "The plunger is the part of the syringe that moves back and forth to withdraw and instill medication." "The barrel is the part of the syringe that resets the dose window to zero following an injection." "The barrel is the part of the syringe to which the needle is attached." "The plunger is the part of the syringe that holds the medication."

"The plunger is the part of the syringe that moves back and forth to withdraw and instill medication."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? "Your wound will heal slowly as granulation tissue forms and fills the wound." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound."

A client is to take Demerol 35 mg IM. You have Demerol 50 mg per ml. How many ml will you administer? 0.5 ml 0.7 ml 0.9 ml 1.3 ml

.7

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? 0.45% NS 0.9% NS 3% NS D5 ¼ NS

.9% NS

The nurse is to administer levothyroxine 0.125 mg PO at 0600. The package is labeled levothyroxine 125 mcg. Calculate the number of tablets the nurse will administer. Record your answer as a whole number.

1 The nurse converts mg to mcg. 0.125 mg is equal to 125 mcg. The nurse will administer 1 tablet. Desired dose is 125 mcg. Dose on hand or supplied dose is 125 mcg. Quantity is 1 tablet.

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug? 15-degree angle 45-degree angle 90-degree angle 120-degree angle

15 degree angle

The health care provider prescribes ciprofloxacin 500 mg PO q12h for a pediatric client with bronchial pneumonia. The nurse has liquid ciprofloxacin 250 mg/10 mL on hand. How many milliliters would the nurse dispense? Record your answer using a whole number.

20

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? 5 minutes 10 minutes 15 minutes 20 minutes

5 minutes

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span.

An infant's skin and mucous membranes are easily injured and at risk for infection.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauze

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area.

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 larger syringe is required when giving an intramuscular injection on an obese person. As the gauge number becomes larger, the diameter of the needle and the lumen become smaller. When giving an injection, the amount of the medication directs the choice of gauge. The size of the syringe is directed by the viscosity of the medication to be given.

As the gauge number becomes larger, the diameter of the needle and the lumen become smaller.

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply. Do nothing as long as Client B has no reaction. Tell Client A that the wrong drugs were given to Client B. Assess Client B thoroughly. Complete an incident report. Contact the provider to report the error.

Assess Client B thoroughly. Complete an incident report. Contact the provider to report the error.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? Assess the client's wound and vital signs. Administer the prescribed analgesic. Notify the health care provider of the pain. Document the pain and vital signs.

Assess the client's wound and vital signs

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? Discontinue the therapy and assess the client. Notify the health care provider of the findings. Document the findings in the client's medical record. Gently rub and massage the area to warm it up.

Discontinue the therapy and assess the client.

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy. Which interventions should the nurse follow to apply the T-binder? (Select all that apply.) Fasten the crossbar around the waist. Pass the tails through the client's legs. Clean the insertion in a circular manner. Pin the tails to the belt of the T-binder. Place the precut drain sponge on the anus.

Fasten the crossbar around the waist. Pass the tails through the client's legs. Pin the tails to the belt of the T-binder.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? Pasta salad Fish Banana Green beans

Fish

The telehealth nurse receives a call from a client who is using a topical nasal decongestant and states, "I feel like my nose is stuffier than ever." What is the appropriate response by the telehealth nurse? "How often are you administering the nasal decongestant?" "Please hang up and call 9-1-1. This is an emergency." "Increase the frequency of taking this drug to help ease the congestion." "Are you willing to take an over-the-counter cold remedy to more fully treat your symptoms?"

How often are you administering the nasal decongestant?"

The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention? "I will wear gloves when applying this." "I will apply this as frequently as prescribed." "I am taking tadalafil in addition to nitroglycerin." "I understand that this drug may lower my blood pressure."

I am taking tadalafil in addition to nitroglycerin."

An emergency room nurse is ordered to administer nitroglycerin to a client being treated for acute pulmonary hypertension. Which means of drug administration would the nurse use to achieve rapid results in this emergency situation? IV Infusion Oral powder Subcutaneous injection Inhalation

IV infusion

The nurse is preparing to administer a nasal spray. Place the nurse's actions in order, from first to last. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Identify the client using two identifiers and verify any allergies. 2Offer the client a tissue and ask the client to blow the nose. 3Insert the tip of the nasal spray into one nostril and close the other nostril with a finger. 4Compress the nasal spray while the client breathes in through the nose. 5Remove the tip of the spray from the client's nostril and release the compression. 6Instruct the client to not blow the nose for 5 to 10 minutes.

Identify the client using two identifiers and verify any allergies. Offer the client a tissue and ask the client to blow the nose. Insert the tip of the nasal spray into one nostril and close the other nostril with a finger. Compress the nasal spray while the client breathes in through the nose. Remove the tip of the spray from the client's nostril and release the compression. Instruct the client to not blow the nose for 5 to 10 minutes.

Which situation accurately describes a recommended guideline when administering oral medications to clients? Assume that the client is the authority on whether or not the medication was swallowed. If a pill is dropped, it should be briefly immersed in saline to remove any dirt or germs. If a client vomits immediately after receiving oral medications, readminister the medication. If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food.

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? It is a battery-operated device that spins. It suspends finely powdered medication. It is a canister that contains pressurized medication. It has propellers that get activated during inhalation.

It is a canister that contains pressurized medication

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? It is used to administer medication only to older adult clients. It is used to administer small volumes of IV medication. It is used to administer medication in a large volume of blood. It is used when IV medications are irritating to peripheral veins.

It is used to administer small volumes of IV medication.

Which contains all the components of a valid order? John Smith, warfarin, once a day, by mouth John Smith, atenolol 50 mg, twice a day, by mouth John Smith, enoxaparin sodium 120 mg, subcutaneously, periumbilical John Smith, 70 units, b.i.d., SL

John Smith, atenolol 50 mg, twice a day, by mouth

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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

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

The nurse is reviewing a medication prescription for a client prior to administration and observes that the route of administration is not present in the prescription. What is the appropriate action by the nurse to address this omission? Add the route to the prescription and administer the medication since the nurse is familiar with the drug. Notify the health care provider to add the route and then administer the medication when complete. Call to ask the pharmacy how the drug should be administered. Omit the administration of the medication since it was written incorrectly.

Notify the health care provider to add the route and then administer the medication when complete.

The client reports dry mouth following chemotherapy treatments. The nurse is administering oral medications to the client. What action will the nurse perform to aid the client in taking medications? Offer a sip of water prior to the administration of the medication. Have the client gargle with an alcohol-based mouthwash. Crush the pills and mix the pills in applesauce. Instruct the client to chew the pills before swallowing.

Offer a sip of water prior to the administration of the medication.

Nurses who will soon complete their 12-hour shift are preparing to account for controlled substances. Which nursing action is appropriate? Select all that apply. One nurse signs off that all controlled substances are reconciled. One nurse counts the supply; another nurse checks the record of administration. The amount of opioids does not have to be recorded. No action is necessary; controlled substance accountability takes place every 24 hours. Two nurses must ensure that the counts of controlled substances agree.

One nurse counts the supply; another nurse checks the record of administration. Two nurses must ensure that the counts of controlled substances agree.

The nurse is caring for an adult client who is receiving medication transdermally. What action by the nurse is most important to ensure the safety of the client? Donning gloves prior to administration of the patch Applying the patch to a clean, dry, hairless, and intact area of skin Writing the date, time, and nurse's initials on the new patch Removing or ensuring the removal of the previous patch

Removing or ensuring the removal of the previous patch

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

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

The nurse is preparing to withdraw medication from an unbroken glass ampule. Which nursing actions are appropriate? Select all that apply. Tap the top of the ampule. Don sterile gloves before opening the ampule. Snap the neck of the ampule while holding it close to the nurse's body. Avoid allowing the needle to touch the outside of the ampule. Invert the ampule to withdraw medication.

Tap the top of the ampule. Avoid allowing the needle to touch the outside of the ampule. Invert the ampule to withdraw medication.

A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason? The site is in close proximity to the sciatic nerve. The area is free of major blood vessels and fat. There is a high possibility of injecting into subcutaneous fat. The site lies close to the radial nerve.

The area is free of major blood vessels and fat.

The nurse is teaching a client about metformin SA. When the client asks, "What does the SA mean?" what is the appropriate nursing response? "sustained release" "continuous release" "extended release" "sustained action"

sustained action

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity? Therapeutic range Peak level Trough level Half-life

therapeutic range

The nurse is preparing to administer a transdermal medication. How should this be accomplished? The nurse should apply the medication directly to the skin. The nurse should inject the medication just below the dermis of the skin. The nurse should ask the client to swallow the medication. The nurse should inject the medication into a body cavity.

The nurse should apply the medication directly to the skin.

Which nursing strategy should the nurse employ to enhance the teaching/learning process for a client who is noncompliant with inhalers? The nurse should use a nebulizer as an alternative to administering an inhalant. The nurse should provide simple written instructions with each medication. The nurse should assess the integrity of mucous membranes very often. The nurse should contact the client's physician for a trial use of a spacer

The nurse should provide simple written instructions with each medication.

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

swallowing the medication

The nurse enters a client's room to administer preoperative antibiotics. Which rights of medication administration must the nurse follow? Heart rate Blood type Time Room

Time

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time

a client sitting in a chair who slides down

To which client would the nurse be most likely to administer a PRN medication? a client who is reporting pain near the surgical site a client who requires daily medication to control hypertension a client who is experiencing severe and unprecedented chest pain a client whose asthma is treated with inhaled corticosteroids

a client who is reporting pain near the surgical site

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a sterile, flexible applicator moistened with saline a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette

a sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.

a surgical incision with sutured approximated edges

A nurse is caring for a client with pneumonia at a health care facility. The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which component is a required component of the medication order? client's name client's age client's diagnosis client's signature

client's name

A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration? Deltoid Vastus lateralis Ventrogluteal Scapula

deltoid

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish color

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? transparent film hydrocolloid hydrogel alginate

hydrocolloid

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? avulsion abrasion incision laceration

incision

A 2-year-old child has been injured in a motor vehicle accident and is in immediate need of a blood transfusion for profuse bleeding. Which access site might the nurse expect to use for the infusion? Antecubital Dorsalis pedis Great saphenous vein Scalp vein Intraosseous access

intraosseous access

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

larger diameter

The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed? miconazole oxymetazoline bisacodyl timolol

miconazole

A nurse has to administer a subcutaneous injection to a client. For which client can the nurse administer a subcutaneous injection at a 90-degree angle? infant thin client child obese client

obese client

The client cannot swallow and just had an enteral tube placed for feeding and medications. Medications will have to be in liquid form or crushed for administration. The client has the following medications prescribed. Which medication will the nurse withhold and consult with the health care provider? furosemide liquid oxycodone extended release tablet acetaminophen tablet aspirin chewable tablet

oxycodone extended release tablet

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing dead or infected tissue to promote wound healing stimulating the wound bed to promote the growth of granulation tissue removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin

removing dead or infected tissue to promote wound healing

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication? read and compare labels on the medication with the medical record review the client's medication, allergy, and medical history administer medication within 30 to 60 minutes of the scheduled time allow sufficient time to prepare the medication with minimal distraction

review the client's medication, allergy, and medical history

What would be considered a "right" of drug administration? Select all that apply. right drug right documentation right class right dose right client

right drug right documentation right dose right client

The nurse is caring for a client who has been prescribed an enteric-coated drug. Which should the nurse include when teaching the client proper administration of this drug? It can be cut into smaller pieces. It should not be chewed or crushed. It should not be opened. It is available in liquid form if needed.

should not be chewed or crushed

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? turbo-inhaler metered-dose inhaler spacer nasal drops

spacer

The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? Standing order Stat order Single order "As needed" order

standing order

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients? gluteus maximus ventrogluteal rectus femoris upper chest

ventrogluteal

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

when the client has disorders that affect the absorption of medications