Fundamentals PrepU: Chapter 29

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.

The nurse is preparing to administer a transdermal medication. How should this be accomplished?

The nurse should apply the medication directly to the skin.

A nurse is in the process of converting a continuous IV infusion to an intermittent infusion device. The nurse has clamped off the primary IV tubing, donned clean gloves, clamped the extension tubing and disconnected the primary IV tubing. The nurse is now cleansing the port on the extension tubing with an antiseptic swab. The nurse cleanses the port for which duration of time?

15 seconds

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

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 extendedFollowing an allergic reaction to a medication, the nurse should: release."

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?

"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."

Which actions by the nurse will prevent injury while withdrawing medication from an ampule? Select all that apply.

1) snapping the neck of the ampule away from his/her body 2) discarding the ampule in a puncture-resistant container 3)using a gauze square to hold the ampule while breaking it

The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?

10 to 15 degrees

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 taking care of a 56-year-old man with end-stage liver disease. The nurse has a prescription to give 20 g of lactulose every 6 hours to treat the client's hepatic encephalopathy. On hand, the nurse has containers of lactulose that have 30 g in 45 ml. How many milliliters is the nurse going to administer every 6 hours to the client?

30 mL

The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?

90 degrees

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 remain lying down for at least 5 minutes.

The nurse is preparing to administer a liquid form of medication to a client. What action will the nurse take to ensure that administration of the drug is at the desired potency?

Check the expiration date.

The nurse is preparing to give medications to a client with high blood pressure. The prescription indicates that the client is to have the combination drug dextroamphetamine saccharate-amphetamine aspartate monohydrate-dextroamphetamine sulfate-amphetamine sulfate 40 mg by mouth twice daily. What is the appropriate nursing action?

Contact the health care provider for clarification of the prescription.

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?

Deltoid

In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?

Discard the remaining drug.

The nurse prepares to administer an antihypertensive medication at 0900 for a client who has problems swallowing and has a blood pressure of 88/50 mm Hg. Which action should the nurse perform when administering the medication?

Do not administer the medication with blood pressure 88/50 mm Hg.

A nurse is administering an intradermal injection to a client for a skin allergy test. When the nurse is finished, there is no sign of a wheal or blister at the site of injection. What is the nurse's best action in this situation?

Document the administration and inform the primary care provider.

A client with a new diagnosis of glaucoma (increased pressure within the eye) has been prescribed a medication that is to be administered by an eye drop. Which action should the nurse perform?

Ensure that drops of the medication fall onto the client's conjunctival sac.

Which situation accurately describes a recommended guideline when administering oral medications to clients?

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

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

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 canister that contains pressurized medication.

A nurse preparing medication for a client is called away to an emergency. What should the nurse do?

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?

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

After administering ear drops to a client, how does the nurse ensure the medication is delivered completely?

Place gentle pressure on the tragus after administration.

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

Pull the client's ear up and back.

The nurse is preparing to administer a tuberculin test to a client. Which instructions should the nurse provide to the client?

Return in 48 to 72 hours for results.

The nurse is preparing to administer a bolus of furosemide 0.8 mg to a client with congestive heart failure and kidney disease. Which right of drug administration would the nurse question and confirm in this client?

Right drug

A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?

Select another site.

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication?

Set the antihypertensive dose aside pending assessment.

A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?

Tactfully request the provider to input the order into the computerized provider order system.

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 area is free of major blood vessels and fat.

Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler?

The nurse should use a nebulizer to administer the medication.

A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?

The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly.

Regarding medication administration, what must occur at the change of shifts?

The opioids for the division are counted.

The client states "I think my IV dressing needs to be changed." In which instance should the nurse change the dressing?

When the dressing is loose, bloody or wet.

A client has an intermittent infusion device inserted for the administration of antibiotic therapy every 6 hours. The nurse would expect to flush the device at which frequency?

before and after each medication administration

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

checking for documented allergies to food or drugs

A client is receiving a secondary infusion of a new antibiotic through a peripherally inserted central line (PICC) suddenly reports itching and flushing. Which action should the nurse prioiritize for this client?

clamp the antibiotic infusion

Following an allergic reaction to a medication, the nurse should:

instruct the client to wear an identification bracelet addressing the allergy.

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

intradermal

A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?

intramuscular

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

A client with chronic obstructive pulmonary disease has been prescribed a bronchodilator to be administered by small-volume nebulizer. The nurse should ensure that the client:

takes rapid, shallow breaths until the medication is complete.

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