Ch 20 Prep U Questions

What action should the nurse take when giving an intramuscular injection using the Z-track method?

Do not massage the site because it may cause irritation.

The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention?

"I am taking tadalafil in addition to nitroglycerin."

The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?

15-degree angle

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

1mL

The nurse is preparing to administer insulin to an older client who is frail and has failure to thrive. At what angle will the nurse plan to insert the needle into the client?

45 degrees

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?

Avoid crushing sustained-release pellets.

An oral medication has been ordered for a client who has a nasogastric tube in place. Which nursing activity would increase the safety of medication administration?

Check the tube placement before administration.

Which technique should the nurse employ when instilling otic medication in an adult ear?

Pull the client's ear up and back.

Which assessment should be conducted by the nurse before the nurse administers tuberculin intradermal injection?

checking for documented allergies to food or drugs

A nurse is administering medication to a 78-year-old female client who experienced symptoms of stroke. When administering the medication prescribed for her, the nurse should be aware that this client has an increased possibility of drug toxicity due to which age-related factor?

decline in liver function and production of enzymes needed for drug metabolism

The Z-track technique is utilized during drug administration by which route?

intramuscular

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

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?

obese clients

Which medications are dropped into the ear to treat ear infections or to soften and remove ear wax?

otic

What type of order would a physician most likely write to treat a client whose pain levels vary widely throughout the day?

prn

Which action made by the nurse demonstrates respect for the client's dignity when administering an intradermal injection?

pulling the curtain or closing the door

What is the best explanation from the nurse as to why a client must return to the unit in 48 hours after having a tuberculin skin test intradermal?

to determine the extent to which the client responded to the drugs

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?

to prevent gastric irritation

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interactions?

use of herbal supplements

Which anatomic site is recommended for intramuscular injections for adults?

ventrogluteal muscles

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."

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 action."

The nurse is caring for a client with diabetes. Which client statement reflects that nursing teaching has been effective?

"I will eat a meal within a half hour of taking my morning insulin."

What is the best response by the nurse when a client asks about the side effects of using nasal spray?

"Long-term use of nasal sprays can cause rebound nasal congestion."

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."

A nurse is administering intramuscular injections to clients on a hospital ward. What needle sizes has the nurse used correctly? Select all that apply.

5/8-inch needle for the vastus lateralis site 1 1/2-inch needle for a child in the deltoid site 1 1/2-inch needle for an adult in the deltoid site 5/8-inch needle for a child in the deltoid site

Which medication interaction illustrates a synergism?

A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy.

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?

Ask the client to maintain the position for some time.

A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order?

Ask the physician to write out the order.

What factor is used to calculate drug dosages for a child?

Body surface area (BSA)

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?

Check the client's identification band.

A nurse is applying a vaginal cream to a client with a vaginal infection. What is a recommended guideline for this application?

Cleanse area at vaginal orifice with washcloth and warm water.

The nurse is preparing to give medications to a client with anxiety. The order indicates that the client is to have bupropion, 7.5 mg by mouth twice daily. What is the appropriate nursing action?

Contact health care provider for order clarification.

The nurse is reading a medication order for a drug that is routinely administered every 12 hours. The order does not state the frequency of administration. What is the appropriate nursing action?

Contact the health care provider to clarify the order.

When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?

Engage safety shield on needle guard and discard needle appropriately.

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges?

Gauges range from 14 to 29, with 14 being the largest.

Which contains all the components of a valid order?

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

To convert 0.8 grams to milligrams, the nurse should do which of the following?

Move the decimal point 3 places to the right.

The nurse is preparing to administer an oral medication to a client with xerostomia. Which nursing action is appropriate?

Offer a sip of water before administering medication.

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.

The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?

Record "T.O." at the end of the order.

While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?

Report the needlestick to the nurse manager.

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

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

What would be considered a "right" of drug administration. (Select all that apply.)

Right client Right drug Right dose Right documentation

Which "rights" are included in the "six rights for medication administration"? Select all that apply.

Right route Right time Right medication Right dose

The "Rights of Medication Administration" help to ensure accuracy when administering medications. What are some of these six rights? (Select all that apply.)

Route Dosage Client Medication

A nurse needs to administer a subcutaneous heparin injection to a client. Which injection site is most suitable for heparin?

abdomen

A code is called and Nurse A hands several drugs to Nurse B, stating while rushing off, "Give these to my client while I help with the code." What is Nurse B's appropriate response?

State, "I cannot give medications for other nurses."

A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection?

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis.

Which strategy should the nurse use to assist a visually impaired client to distinguish between eye medications?

The nurse should advise the client to use rubber bands on the containers.

Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?

The ventrogluteal site provides a location with the capacity for depositing and absorbing drug.

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect?

Therapeutic range

Which is not true regarding Nurse Practice Acts?

They describe what medications nurses can prescribe.

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?

Vastus lateralis site

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?

Withdraw the needle and release taut skin immediately after injection.

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 canister containing medication that is released when the container is compressed

A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which instructions are stated on the label of a vial container?

amount of diluent to be added

The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not?

aspirating for a blood return

A nurse is caring for a client with typhoid 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

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?

distribution

A nurse is caring for a client with severe lower back pain. The doctor orders administration of an analgesic as a stat dose. When should the nurse administer the medication?

immediately

The nurse is preparing to administer a tuberculin test to a client. Which injection site will the nurse use?

inner aspect of the forearm

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?

intradermal

The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?

intradermal

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?

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

A physician indicates in the medication order for a client with diabetes that the drug is to be taken three times a day. Which standard abbreviation indicates the frequency of administration of the medication?

t.i.d.