fundamentals of pharma
A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe disposal of an unused portion of the medication C. Counting the inventory of the available narcotic after administering the medication D. Making sure that a nurse signs the control inventory form after disposal of an unused portion of the medication
Correct Answer: B. Asking another nurse to observe disposal of an unused portion of the medication The nurse should ask another nurse to witness the disposal of a controlled substance to maintain safe control of the narcotic. Incorrect Answers: A. The nurse should not dispose of an unused portion of a controlled substance in the sharps container because this action does not maintain safe control of the narcotic. C. The nurse should check and count the inventory of the controlled substance before removing a dosage to maintain safe control of the narcotic. D. The nurse should make sure that 2 nurses sign the control inventory form after the disposal of a portion of a narcotic to maintain safe control of the narcotic.
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower inner thigh, 2 finger widths above the patella
Correct Answer: B. The side hip between the iliac crest and anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare the client for injection by placing a hand on the client's greater trochanter (e.g. with the right hand on the client's left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Incorrect Answers: A. To administer an intramuscular medication using the dorsogluteal site, the nurse should select the upper lateral quadrant of the buttock. However, this site can increase the risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is an increased risk of piercing the sciatic nerve. C. The nurse should select the outer posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections of less than 1 mL, the nurse may select the deltoid muscle by placing 4 fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is 3 finger widths below the acromion process or about 5 cm (2 in). D. To administer an intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place a hand below the greater trochanter and the other hand just above the knee to locate the middle portion of the muscle for the injection site.
A nurse is caring for a client who reports using several herbal supplements. Which of the following actions should the nurse take? A. Discourage use of unregulated medications and supplements B. Verify that the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to take no more than 2 herbal supplements D. Review the dangers of taking plant-derived medications and supplements
Correct Answer: B. Verify that the herbal supplements do not interact with medications the provider has prescribed Many herbal products interact with other prescription and nonprescription medications. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider. Incorrect Answers: A. Although herbal products are not subject to the regulation and scrutiny of the U.S. Food and Drug Administration, many of them are safe and potentially effective in treating a variety of health concerns. C. The nurse's responsibility is to obtain a list of all the medications and herbal products the client takes so that the provider can review them and make recommendations. There are no specific limits the nurse should set on how many herbal products the client can use. D. Pharmaceutical companies make many prescription medications from plants (e.g. digoxin, reserpine, aspirin, and morphine).
A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord that is felt along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site
Correct Answer: C. Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress, depending on the type of infiltration. Incorrect Answers: A. A client who has swelling and redness at the IV catheter-skin entry site might have a local infection. The nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location. B. A client who has a palpable cord felt along the vein might have phlebitis, which is inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a new IV line in another location. D. Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should check to determine whether the IV system is intact and the catheter is within the client's vein. The nurse might need to start a new IV line in another location if the bleeding does not stop after interventions.
A nurse is reinforcing teaching with a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of non-adherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials D. Assist the client to identify ways that these changes will result in positive personal outcomes
Correct Answer: D. Assist the client to identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, assisting clients to identify ways that the changes will promote positive outcomes should precede other educational strategies about making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes. Incorrect Answers: A. The client should understand all aspects of the illness in question, as well as the consequences of nonadherence to recommended lifestyle changes. However, when trying to motivate the client to make lifestyle changes, the client might perceive warnings about the dangers of nonadherence as a threat. Instead, the nurse should present this information after the client commits to making the recommended changes. B. Scheduling meetings about psychomotor skills is important for showing the client what to do for self-care. However, this is unlikely to encourage the client to make an initial commitment. Instead, this strategy will help strengthen the client's adherence to the recommended life changes after the client has made an initial commitment to them. C. The client should understand all aspects of the illness, and clearly written and easy-to-understand instructional materials can help. However, the nurse should present this information after the client is committed to change.
A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash can D. Place the syringe in a puncture-proof disposal container
Correct Answer: D. Place the syringe in a puncture-proof disposal container The nurse should place the uncapped syringe in a puncture-proof sharps disposal container or rigid plastic container to prevent a needlestick injury. The nurse should keep the syringe uncapped while placing the cap on the needle and reinforce client education on safety and proper disposal of syringes. Incorrect Answers: A. The nurse should not recap the needle because of the risk of a needlestick injury during this action. B. The nurse should not schedule another nurse to administer future injections for the client. Instead, the nurse should reinforce teaching with the client about potential injuries and infections that can result from a needlestick injury. After exploring the client's reasons for nonadherence to safety measures, the nurse should review appropriate methods of disposal for used syringes. C. The nurse should not instruct the client to dispose of used syringes in a bathroom trash can due to the risk of a needlestick injury when handling the trash.
A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal
Correct Answer: C. Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children. Incorrect Answers: A. The nurse can use the deltoid muscle for injecting small volumes of medication for children 18 months of age and older, but its proximity to several nerves and arteries make it a risky choice. B. This is a safe site for IM injections for clients older than 7 months. D. This site is unsafe to use because of its proximity to the sciatic nerve and the superior gluteal nerve and artery.
A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take? A. Smear the small amount of blood onto the testing strip B. Hold the finger above heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth
Correct Answer: D. Wrap the client's finger in a warm washcloth Warmth helps increase the blood flow to the client's finger. Incorrect Answers: A. Smearing the blood on the reagent strip will cause an inaccurate result. B. To improve blood flow, the nurse should keep the client's hand in a dependent position. C. Massaging can hemolyze the specimen, causing an inaccurate result.
A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) "Hold your breath for 10 seconds." "Depress the canister while taking a slow, deep breath." "Tilt your head back slightly and open your mouth wide." "Hold the mouthpiece 1 to 2 inches in front of your mouth."
Correct Answer: Step 1. The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from the mouth Step 2. The client should tilt the head back slightly, and then open the mouth. Step 3. The client should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. Step 4. After holding a breath for 10 seconds, the client should resume the usual breathing pattern.
A nurse is reinforcing teaching with the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
Correct Answer: 2 Follow these steps for the conversions of mL to tsp: Step 1: What is the unit of measurement the nurse should calculate? tsp Step 2: Set up an equation and solve for X. 5 mL/1 tsp = 10 mL/X tsp 5X = 10 X = 2 Step 3: Round if necessary. Step 4: Determine whether the conversion to tsp makes sense. If 5 mL = 1 tsp, then 10 mL = 2 tsp.
A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside so she can take it at a later time. Which of the following responses should the nurse provide? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to make sure you took the medication so that I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."
Correct Answer: A. "Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration. Incorrect Answers: B. At home, the client is responsible and accountable for actions regarding the self-administration of medications. In an inpatient setting, the nurse is responsible for administering medication to the client and following the 6 rights of medication administration. C. If the nurse returns to the client's room in 30 minutes, the nurse will not be able to verify that the client took the medication since the client could have hidden or discarded the medication. D. Although the policy about timing varies with each facility, it is generally acceptable to give a medication within 1 hour of the prescribed time (i.e. within 30 minutes before the prescribed time and 30 minutes after the prescribed time of administration).
A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session? A. A simple demonstration of inhaler use B. A discussion of health problems C. Collaboration in instruction D. Mutual goal-setting
Correct Answer: A. A simple demonstration of inhaler use For preschoolers, simple explanations and demonstrations are developmentally appropriate. The nurse should explain how the inhaler works and demonstrate its use (without the medication canister inside it). To make sure the client knows how to use the inhaler, the nurse should ask for a return demonstration. Incorrect Answers: B. Incorporating a discussion of health concerns and problems is a useful strategy for school-aged children, not for preschoolers. C. Preparing instructional sessions as a collaboration between the nurse and the client is a useful strategy for adolescents, not for preschoolers. D. Setting learning goals mutually is a useful strategy for young adults, not for preschoolers.
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac. B. Apply gentle pressure in the outer opening of the eye for 2 minutes C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close eyes tightly after administration
Correct Answer: A. Drop the eye medication into the lower conjunctival sac. The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. Incorrect Answers: B. The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye. C. The nurse should hold the eyedropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea from injury by preventing the tip of the dropper touching the eye. D. The nurse should instruct the client to close the eyes gently when applying ointment or liquid to distribute and avoid expelling the medication and to avoid injuring the eye.
As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle when measuring
Correct Answer: A. Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold the multidose bottle with the label against the palm of the hand when pouring to avoid contaminating the label with spilled medication, which could cause information on the label to fade or become illegible. Incorrect Answers: B. The nurse should remove the cap of the medication bottle and place it with the inside of the cap facing up on a hard surface to prevent contamination of the inside of the cap and to maintain cleanliness. C. The nurse should fill the cup until the medication is even with the surface or base of the meniscus of the dosage scale to ensure the client receives an accurate dose of the medication. D. The nurse should discard any excess liquid into the sink as wasted medication and should wipe clean the lip of the bottle after measuring.
A nurse is preparing to administer a medication to a client. Which of the following administration schedules indicates that the nurse should administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription
Correct Answer: A. Stat prescription The nurse should identify that a stat medication prescription is carried out immediately and one time only. Incorrect Answers: B. A PRN prescription refers to administering a medication as needed. C. A standing prescription indicates the frequency at which a prescribed medication is administered on a daily basis and might not have any specific cancelation date. D. A single prescription refers to administering a medication once at a specified time.
A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication."
Correct Answer: C. "I will shake the inhaler well right before I use it." The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. Incorrect Answers: A. The nurse should instruct the client to rinse the mouth with water following the use of the inhaler to reduce irritation and infection, not before using the inhaler. B. The nurse should instruct the client to wait 20 to 30 seconds between inhalations of bronchodilator medications such as albuterol. D. The nurse should instruct the client to place the inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal. The client should then depress the canister, take a deep breath, and hold it for at least 10 seconds.
A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instillation of the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the bridge of the nose after instillation of the medication D. Place each drop of the medication directly on to the client's cornea
Correct Answer: C. Apply pressure to the bridge of the nose after instillation of the medication The nurse should instill timolol into the conjunctival sac and apply pressure to the bridge of the nose for 1 minute afterward to prevent systemic absorption of the medication. Incorrect Answers: A. The nurse should instruct the client to close the eyes gently and to avoid blinking after instillation to prevent loss of the medication out of the eye and to promote absorption. B. The nurse should instruct the client to look at the ceiling during instillation of the medication to allow proper placement of the medication and to suppress the client's blink reflex. D. The nurse should instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during the administration of the medication.
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date
Correct Answer: C. Compare the medical record number and name on the MAR with the client's identification band The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band. Incorrect Answers: A. The room and bed numbers are not acceptable identifiers. B. This client cannot respond to her name. D. A visitor is not an acceptable source for identification.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye
Correct Answer: C. Exert pressure on the bony prominences when holding the eyelids open The nurse should hold the client's upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. Incorrect Answers: A. The nurse should hold the irrigator 2.5 cm (1 in) above the eye to keep the irrigator from touching the eye and to prevent the solution from damaging the eye tissue. B. The nurse should direct the irrigation solution onto the lower conjunctival sac to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. D. The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.
A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take? A. Make sure the drops are at room temperature B. Wear sterile gloves during the instillation C. Have the client lie on the side opposite the infected ear D. Pull the client's pinna downward to straighten the ear canal
Correct Answer: C. Have the client lie on the side opposite the infected ear This position allows optimal access for instilling the drops. A sitting position with the client's head leaning toward the unaffected ear is also acceptable. Incorrect Answers: A. The nurse should warm the medication before instillation to avoid nerve stimulation and discomfort. B. The nurse should wear clean gloves during the instillation. D. For adults, the nurse should pull the pinna upward to straighten the ear canal. For children younger than 3 years, pulling the pinna down and back will straighten the canal.
A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site
Correct Answer: C. Remove the IV catheter The client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site. Incorrect Answers: A. The client's manifestations do not suggest that the infusion tubing is punctured, contaminated, occluded, or expired. B. This action could worsen the complication suggested by the client's manifestations. D. Warm, moist heat is part of the treatment protocol for the complication suggested by the client's manifestations.
A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall
Correct Answer: C. Use the index finger to insert the suppository To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. Incorrect Answers: A. The nurse should wear clean gloves for this procedure, not sterile gloves. B. The nurse should use the nondominant hand to retract the labia and the dominant hand to insert the suppository. D. The nurse should ease the suppository along the posterior vaginal wall.
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infectives D. Plasma volume expanders
Correct Answer: D. Plasma volume expanders Dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as after hemorrhage or burns. Incorrect Answers: A. Dextran is not a skeletal muscle relaxant. Examples of skeletal muscle relaxants are cyclobenzaprine and metaxalone. B. Dextran is not a beta-adrenergic blocker. Examples of beta-adrenergic blockers are propranolol and carvedilol. C. Dextran is not a broad-spectrum anti-infective. Examples of broad-spectrum anti-infectives are ampicillin and cefixime.
A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Administer the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage
Correct Answer: D. Call the provider to clarify the dosage After collecting data from the client to check for adverse effects of the medication, the nurse should notify the provider of her observations to determine the next action. Incorrect Answers: A. The MAR indicates what dosage the nurse administered. B. It is not within the nurse's scope of practice to change the medication dosage. C. The nurse has identified a potential problem with the prescribed dosage; therefore, the nurse should not give that dosage.
A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A. Document the administration of the medication B. Count the available medication and sign for it C. Measure the client's respiratory rate D. Check the medication dose and the client's identification
Correct Answer: D. Check the medication dose and the client's identification The "rights" of medication administration include verifying the right client and the right dose. Incorrect Answers: A. The nurse should document the administration of the medication after administering it, not before. B. Phenytoin is not a controlled substance, so narcotic counts do not apply. C. Phenytoin does not affect respiratory status, so the nurse does not need to measure the client's respiratory rate immediately prior to administering this medication.
A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25º angle C. Massage the injection area following removal of the needle D. Circle the area of the injection with a pen
Correct Answer: D. Circle the area of the injection with a pen Circling the area using a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later. Incorrect Answers: A. A 25- to 27-gauge needle is used for intradermal injections. B. The needle should be inserted at an angle of 10º to 15º. This ensures the solution will be injected into the intradermal area. C. The area should not be massaged because this can spread the injection into the tissue or out through the insertion site.
A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take? A. Position the head of the client's bed at 15 degrees° B. Mix the medications together in a medication cup C. Pour the medications into the enteral formula container D. Flush the tube with water before and after instilling each medication
Correct Answer: D. Flush the tube with water before and after instilling each medication This action clears the tube of any residual stomach contents after measuring residual volume and ensures that each medication reaches the client's stomach. Incorrect Answers: A. The nurse should elevate the head of the client's bed by at least at 30º and preferably 45º as a precaution against aspiration. B. The nurse should administer each medication separately and not mix them to avoid interactions or clumps that could obstruct the tube. C. The medications could interact with the formula, so the nurse should not use this method of delivery. If the client is receiving continuous enteral feeding, the nurse might have to stop the formula instillation temporarily. The pharmacist can advise the nurse of any such precautions for the medications the client is receiving.
A nurse is administering a controlled substance to a client who is postoperative. The IM dosage requires the nurse to use only part of the amount of medication in the vial. Which of the following actions should the nurse take? A. Lock the vial in the controlled-substances cabinet for later use B. Crush the vial between 2two paper towels and place it in a sharps container C. Return the opened vial to the pharmacy D. Have another nurse witness the disposal of the medication
Correct Answer: D. Have another nurse witness the disposal of the medication When using only a portion of a vial of a controlled substance, the nurse must discard the remainder safely and in a way that makes it impossible to retrieve such as by injecting it out of a syringe into a sink or toilet and rinsing or flushing it. Another nurse witnesses the process and signs the controlled inventory form or other documentation. Incorrect Answers: A. Placing an open vial of a controlled substance anywhere on the nursing unit, even in a locked cabinet, could result in another staff member using or tampering with it. This would be an unsafe action. B. Handling broken glass could cause an injury, especially if the nurse tried to separate the glass shards from the paper towels. This would be an unsafe action. C. There is potential for abuse if the nurse sent or transported an opened vial of a controlled substance to another department, even to the pharmacy. This would be an unsafe action.
A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly B. Instruct the client to look at the floor while instilling the eye drop C. Remind the client to avoid using a facial tissue after instillation D. Instruct the client to apply pressure to the inside corner of the eye after instillation
Correct Answer: D. Instruct the client to apply pressure to the inside corner of the eye after instillation The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result. Incorrect Answers: A. One of the actions the client took is incorrect. B. The nurse should instruct the client to look up when instilling the eye drops. C. The nurse should instruct the client that it is acceptable to use a tissue to remove excess medication after instillation.
A nurse is planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client? A. Speak loudly to the interpreter B. Make eye contact with the interpreter when instructing the client about the procedure C. Use metaphors and colloquial expressions D. Make sure the client and the interpreter are culturally compatible
Correct Answer: D. Make sure the client and the interpreter are culturally compatible It is important that the interpreter and the client speak the same dialect. The nurse should also understand any cultural norms or practices that could make the interaction uncomfortable. Incorrect Answers: A. The nurse should speak clearly, not loudly, and should direct speech to the client rather than the interpreter. It is generally easier for an interpreter to translate speech that sounds natural with an average volume, a slow-to-average speed, and a normal rhythm. B. The nurse should make eye contact with the client and direct questions, instructions, and information to the client, not to the interpreter. This conveys that the nurse is focusing on the client. C. To avoid potential misinterpretation, the nurse should avoid the use of metaphors and colloquial expressions that might be challenging to translate or whose literal translations might convey an unintended message.
A nurse is preparing a liquid medication from a multi-dose bottle prior to administering it to a client. Which of the following actions should the nurse take? A. Make sure the label on the bottle faces downward when pouring the medication B. Place the medication cup on a paper towel C. Check that the mark for the dosage matches the fluid level at the top of the meniscus D. Place the cap of the bottle upside down on a clean surface
Correct Answer: D. Place the cap of the bottle upside down on a clean surface The nurse should place the cap of the bottle upside down on a clean surface to keep the cap clean and avoid contaminating the inside of the cap. Incorrect Answers: A. The nurse should have the label face upward so that the medication does not run down onto the label, possibly distorting the printed information on the label. B. The nurse should place the cup on a hard surface to help with measuring the dosage accurately. A paper towel could tilt the cup slightly. C. The nurse should make sure that the base of the meniscus (the curved upper surface of the liquid) aligns with the mark on the cup that indicates the correct dosage.
A nurse is caring for a client who is receiving an IV infusion of 5% dextrose in lactated Ringer's. The nurse notices that the area around the catheter insertion site is edematous and cooler than the surrounding skin on the forearm. Which of the following actions should the nurse take? A. Switch the fluid to 0.9% sodium chloride B. Place the arm in a dependent position C. Prepare to administer a diuretic D. Stop the infusion
Correct Answer: D. Stop the infusion Coolness and swelling at the insertion site indicate an infiltration. The nurse should stop the infusion, remove the catheter, and report the situation to the charge nurse and the provider. Incorrect Answers: A. Switching the IV fluid from a hypertonic to an isotonic solution will not correct the edema and coolness at the catheter's insertion site. B. When there is swelling from an IV infusion, the nurse should elevate the extremity. C. Providers prescribe diuretic therapy when there is evidence of circulatory overload such as from a rapid infusion rate. Diuretics will not remove the fluid causing the edema at the catheter's insertion site.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse caring for this client? (Select all that apply.) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics
Correct Answers: B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics The nurse should report any changes to the client's treatment in the nursing handoff report. For a client who is receiving mechanical ventilation, the latest arterial blood gas results and tracheal secretion characteristics reflect the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report. Incorrect Answers: A. Unless it is extreme, the room temperature should not affect the client's care and should not be included in a nursing handoff report. C. Unless there is a specific issue or concern about visitors, it is not necessary to report the number of visitors the client had in the handoff report.
