PrepU Med Admin, Sterile Technique, Nursing Process

A nurse is conducting an interview with a client to collect a medication history. Which question would be used to ensure safe medication administration?

"Do you have any allergies to medications?"

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?"

The nurse is preparing to administer medications to a client. The client asks, "Why are you using this to give me my medication?" After reviewing the image above, what is the best response by the nurse?

"I am using this machine to scan the code on your wrist to identify and verify the medications prescribed for you before you receive them."

The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?

"I feel like my back and arms are itching."

A nurse is teaching an older adult about taking newly prescribed medications at home. Which information would be included?

"I have written the names of your drugs with times to take them."

Which statements by the nurse demonstrate understanding of the appropriate way to document an error in charting?

"If I make an error, I draw a single line through it and put my initials by it."

The nurse is teaching a client about venlafaxine XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response?

"It means extended release."

A nurse is admitting an older client named Grace Staples to a long-term care facility. How should the nurse address the client?

"What name do you want us to use for you?"

The nurse is teaching a client about indomethacin SR. When the client asks, "What does the SR mean?" what is the appropriate nursing response?

"sustained release"

A client has an order for chloramphenicol, 500 mg every 6 hours. The drug comes in 250 mg capsules. What would the nurse administer?

2 tabs

Nursing students need to learn to care for themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of client care?

A sense of humor, anticipation of loss, and developing negative body image

A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next?

Assess the client and notify the client's health care provider.

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

Assessing

A nurse is caring for a client with conjunctivitis. The health care provider prescribes eyedrops to be administered stat. Which action by the nurse demonstrates safe instillation?

Avoid dropping the drops directly on the cornea.

An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization?

Centers for Disease Control and Prevention (CDC)

A nurse is administering an antihypertensive drug to a hospitalized client. Which action should the nurse take to identify the client prior to administration?

Check the client's ID bracelet.

The nurse is performing a sterile change of a client's central line catheter dressing. The client receives a telephone call and stretches the phone cord across the open sterile dressing kit. What is the next best action the nurse should take?

Collect another sterile central line dressing kit.

The nurse is reading a medication prescription for a drug that is routinely administered every 12 hours. The prescription does not state the frequency of administration. What is the appropriate nursing action and accompanying rationale that guides the nurse's action?

Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration.

A nurse educator is reviewing information related to medication administration documentation with a group of graduate nurses. Which guideline for documenting will the nurse discuss with the group?

Document administration of the medication immediately after administering the drug.

In which order should the nurse instruct the client to follow when inserting vaginal medication?

Empty your bladder just before inserting the medication. Lubricate the applicator tip with water-soluble lubricant. Lie down, bend your knees, and spread your legs. Separate the labia and insert the applicator into the vagina, and insert the medication. Remain recumbent for at least 30 minutes. Wash and store the reusable applicator properly.

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure?

Gather new sterile supplies and start over.

When the nurse is administering Lasix 20 mg to a patient in congestive heart failure, what phase of the nursing process does this represent?

Implementation

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

The nurse is caring for a client who just returned from the postanesthesia care unit and rates current pain as "9 out of 10." Which prescribed medication would provide the fastest relief from pain?

Intravenous morphine sulfate

Which actions would a nurse perform when instilling eardrops correctly? Select all that apply.

Invert and hold the dropper in the ear with its tip above the auditory canal. Clean the external ear with cotton balls moistened with normal saline solution. Straighten the auditory canal by pulling the cartilaginous portion of the pinna up and back in an adult (or down and back in an infant or child under 3 years). Hold the dropper in the ear with its tip above the auditory canal.

The nurse has entered a patient's room to find the patient diaphoretic (sweat-covered) and shivering, inferring that the patient has a fever. How should the nurse best follow up this cue and inference?

Measure the patient's oral temperature.

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes

Nurses play a key role in reducing both the spread of disease and adverse outcomes for clients. Which statement accurately describes this process? Select all that apply.

Nurses practice asepsis, which encompasses all activities to prevent infection. Nurses practice medical asepsis, which involves procedures and practices that reduce the number and of pathogens and the transfer of these pathogens. Nurses perform surgical asepsis, which is intended to keep objects and areas free from microorganisms. Nurses use Standard and Transmission-Based Precautions as an important part of preventing infection.

What must a nurse do each time medications are administered to ensure that medication errors do not occur?

Observe the three checks and rights of administration.

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?

Obtain a new bottle of sterile saline.

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action?

Open a new sterile dressing kit

A nurse is preparing to administer several prescribed medications to a client. The medications ordered are to be given by the following routes: oral, subcutaneous, intramuscular and intravenous. Place the routes in the proper order from slowest to fastest absorption.

Oral Subcutaneous Intramuscular Intravenous

When administering oral medications, which practices should the nurse follow? Select all that apply.

Perform hand hygiene before and after medication administration. Stay at the bedside until the client has swallowed all the medications. Verify the client's response to the medication 30 minutes after administration or as appropriate for the drug.

A client has been prescribed a drug that will be administered by buccal application. Which should the nurse tell the client regarding buccal application of the drug?

Place the medication against the mucous membrane of the inner cheek.

What technique should the nurse use to implement infection control in the home?

Practice hand hygiene when beginning and ending the home visit.

Which nursing actions should be performed in the required checks for safe medication administration? Select all that apply.

Read the medication label when reaching for the unit dose package. Read the medication label after retrieving the medication from the drawer. Read the medication label just before administering a unit dose medication to the client.

An operating room (OR) nurse on the facility's infection control team notices that a coworker in the OR is wearing artificial nails. What is the appropriate action/response by the nurse?

Remind coworker that artificial nails increase infections

A physician writes an order for ampicillin 1 gram every 6 hours for Mr. Jameson Owens. What is missing in this order?

Route

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician?

SBAR

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention?

Sitting with the client to encourage the client to talk

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field?

Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves.

The nurse observes a surgeon explaining the procedure for an appendectomy to a client and asking the client to sign the consent for surgery. The nurse is aware that the client does not speak the language being used fluently. Which is the best action for the nurse to take to advocate for the client?

Suggest that a hospital interpreter explain the procedure to the client before the consent is signed.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. Which would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

Which pharmacological consideration should the nurse consider when applying a medication patch to a client?

The nurse is to use gloves to apply and wash hands after.

An operating room nurse is putting on sterile gloves to assist with client surgery. Which actions are performed correctly in this procedure? Select all that apply.

The nurse opens the outside wrapper by carefully peeling the top layer back. The nurse carefully opens the inner package by folding open the top flap, then the bottom and sides. The nurse lifts and holds the glove up and off the inner package with fingers down and carefully inserts hand palm up into glove.

The nurse is preparing to administer nasal medications to a client. In which order is the nurse is expected carry out the procedure?

The nurse will help the client to a sitting position with the client's head tilted backward. The nurse will aim the tip of the container towards the nasal passage and squeeze the number of drops prescribed. The nurse will instruct the client to breathe through the mouth as the drops are instilled. The nurse will advise the client to remain in the position for approximately 5 minutes.

The nurse is removing soiled gloves after assisting with a sterile procedure. Which actions follow recommended guidelines for this procedure? Select all that apply.

Use the dominant hand to grasp the opposite glove near cuff end on the outside exposed area. Remove the glove by pulling it off, inverting it as it is pulled, and keeping the contaminated area on the inside. Slide the fingers of the ungloved hand between the remaining glove and the wrist. Discard the gloves in appropriate container, removing additional PPE, if used, and performing hand hygiene.

The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?

Wait with the client until the medications are taken.

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?

Withhold the medication and notify the health care provider that ordered the medication

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

The nurse is caring for an older adult client who has been prescribed an inhaled bronchodilator. Which priority assessments will the nurse perform before and after administering the medication? (Select all that apply.)

blood pressure heart rate

The nurse is reading an order that indicates that a drug is to be given to a client "q4h." How will the nurse administer the medication?

every 4 hours

Which of the following phrases best describes continuity of care?

facilitating transition between settings

A physician has ordered that a medication be given "stat" for a patient who is having an anaphylactic drug reaction. At what time would the nurse administer the medication?

immediately after the order is noted

Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using?

implementing

The nurse administers medications by various routes of delivery. The nurse should use which route for a client who needs immediate effect of the medication?

intravenous

Which of the following group of terms best describes the nursing process?

patient-centered, systematic, outcomes-oriented

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which would be the most appropriate action for the nurse?

strike out with a single line and place initials

The nurse has received new medication orders for a client that has had a condition change. What components of the medication order's should be present prior to administering the medication? Select all that apply.

the full name of the client the date and time when the order is written or placed in the order entry on the computer the dosage of the drug, stated in either the apothecary or metric system the route by which the drug is to be administered

The nurse is reading an order that indicates that a drug is to be given to a client "t.i.d." How will the nurse administer the medication?

three times daily