Med Admin and Safety

Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the client is having difficulty swallowing. Select all that apply. 1. Debris in the buccal cavity 2. Coughing episodes 3. Noisy breathing 4. Slurred speech 5. Drooling

1, 2, 3, 4, and 5

A confused client is touching his IV line and the nurse is concerned for his safety. The nurse wants to consider options for keeping the IV line from being pulled out. Which of the following options would best meet the needs of the client and nurse? Select all that apply. 1. Explain the purpose of the IV line. 2. Reorient the client by telling him the day and time. 3. Cover up the IV site with a long-sleeved gown. 4. Apply wrist restraints to both wrists. 5. Apply a mitt to both hands without a

1, 2, 3, and 5 Rationale: These four options are alternatives to restraints and it is necessary for the nurse to attempt alternative options before making the decision to call the healthcare provider for an order for restraints (option 4). Orienting the client and explaining the IV device may help depending on the level of confusion and is an intervention for confused clients. Covering up or disguising the device may help by eliminating the strange distraction, and a mitt is considered an alternative as long as it is not tied to the bed and the client can remove it if desired.

A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse's actions in order of priority using the RACE model. 1. Pull the fire alarm 2. Close unit doors and windows 3. Shut the door to the utility room 4. Provide emotional support to agitated clients

1, 3, 2, and 4

A nurse is interviewing a newly admitted client in the process of completing a nursing admission history and physical assessment. Which information should be included in a medication reconciliation form? Select all that apply 1. Vitamins 2. Drug allergies 3. Food supplements 4. Over-the-counter herbs 5. Prescribed medications

1, 3, 4, and 5

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are

1, 3, 4, and 5 Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint.

A primary health-care provider prescribes an oral medication for a client. The nurse identifies that the client is having some difficulty swallowing. What should the nurse plan to do? Select all that apply 1. Crush tablets that are crushable and mix with a small amount of applesauce 2. Have the client hyperextend the neck slightly when swallowing 3. Give water before, during, and after medication administration 4. Stroke under the chin over the larynx 5. Have the client use a straw

1, 3, and 4

A provider prescribe two oral medications for a client with a NG tube on low continuous suction. Which action should the nurse implement? 1. Give each medication separately 2. Follow medication administration with 100 mL of free water 3. Crush crushable tablets into a fine powder and mix with 30 mL of warm water 4. Shut off NG suctioning for 30 minutes after med admin 5. Ensure NG tube placement by instilling 30 mL of air while auscultating over the epigastric area for a "whooshing" sound

1, 3, and 4

The primary care provider prescribed 5 mL of a medication to be given deep intramuscular for a 40-year-old female who is 5'7" tall and weighs 135 pounds. Which is the most appropriate equipment for the nurse to use? Select all that apply. 1. Two 3-mL syringes 2. One 5-mL syringe 3. A #20-#23 gauge needle 4. A 1-inch needle 5. A 1 1/2-inch needle

1, 3, and 5 Rationale: Five milliliters is too large an amount to inject into one site. The nurse needs to divide the amount into two 2.5-mL injections. A 3-mL syringe could be used (option 1). The length of the needle will depend on the muscle development of the client. The nurse needs to assess the client. The presumption, based on the information provided, is that this client's muscle mass is within normal limits. The needle length would need to be 1 1/2 inches because the medication is be given "deep IM" (option 5). This also suggests that the medication should be given in the preferred site for IM injections—the ventrogluteal site—because it provides the greatest thickness of gluteal muscle. The gauge of the needle for an IM injection into the ventrogluteal muscle can range between #20 and #23 (option 3). The nurse needs to assess the viscosity of the medication. Smaller gauges (e.g., #23) produce less tissue trauma; however, viscous solutions may require a larger gauge

A primary health-care provider prescribes a medicated cream for a client to be administered topically to an area excoriated skin. Place the following steps in the order in which they should be implemented. 1. Don clean gloves 2. Evaluate the results of the cream on the skin 3. Warm the tube of medication before application 4. Cleanse the skin gently with soap and water and pat dry 5. Don sterile gloves and apply a thin layer of cream to the desired area

1, 4, 3, 5, and 2

A primary health-care provider prescribe nose drops to be administered twice a day. Which should the nurse do when instilling the nose drops? 1. Tell the client not to sniff the medication once administered 2. Place the client in the supine position with the head tilted backward 3. Pinch the nares together briefly after the drops are instilled 4. Instruct the client to blow the nose 5 minutes after the drops are instilled 5. Insert the drop applicator 1/2 inch into the nose toward the base

1, and 2

A health-care provider prescribes a rectal suppository for an adult client. Which action should the nurse implement when administering the suppository? 1. Lubricate the medication before insertion 2. Warm the medication equal to body temperature 3. Instruct the client to take deep breaths through the mouth 4. Insert the medication just inside the rectum's external sphincter 5. Place the client in the prone position

1, and 3

A nurse is to administer an eye irrigation to a client's right eye. Which should the nurse do? Select all that apply 1. Direct the flow of solution from the inner to the outer canthus 2. Irrigate with a bulb syringe held several inches above the eye 3. Expose the conjunctival sac and hold open the upper lid 4. Don sterile gloves before beginning the procedure 5. Position the client in a right lateral position

1, and 3

According to the 2014 National Patient Safety Goals (NPSGs), what are the ways to improve accuracy of patient information? Select all that apply. 1. Use at least two patient identifiers when providing care, treatment, services 2. Report critical results of tests and diagnostic procedures on a timely basis 3. Eliminate transfusion errors related to patient misidentification 4. Maintain and communicate accurate patient medication information 5. Label all medications, medication containers, and ot

1, and 3

Which routes are unrelated to the parenteral administration of medications? Select all that apply. 1. Buccal 2. Z-track 3. Sublingual 4. Intravenous 4. Intradermal

1, and 3

Which is an appropriately worded goal for a client who is at risk for falling? Select all that apply 1. "The client will be able to walk from a bed to a chair safely while hospitalized." 2. "The client will be taught how to call for help to ambulate." 3. "The client will be kept on bedrest when missy." 4. "The client will be restrained when agitated." 5. "The client will be free from trauma."

1, and 5

When evaluating a parent's further understanding of poisoning prevention, which of the following statements indicates a need for further teaching? 1. "We'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk cartons." 2. "We'll display the phone number of the poison control center near or on all telephones." 3. "We'll teach our children never to eat any part of an unknown plant or mushroom in their mouth." 4. "We'll not refer to medicine as

1. "We'll store toxic liquids or solids in food containers, such as soft drink bottles, peanut butter jars, or milk cartons."

Erythromycin 500 mg is ordered. It is supplied in a liquid form containing 250 mg in 5 mL. How many milliliters would the nurse administer? 1. 10 2. 20 3. 30 4. 40

1. 10

The nurse is preparing a subcutaneous injection for a client. Which of the following statements is correct? 1. A 45 degree angle is used when 1 inch of tissue can be grasped at the site 2. A 90 degree angle is used when 1 inch of tissue can be grasped at the site 3. Generally a 3-to-5 mL syringe is used for most subcutaneous injections 4. A #28 guaze, 1/2 inch needle is used for adults of normal weight

1. A 45 degree angle is used when 1 inch of tissue can be grasped at the site

An older client with renal insufficiency is to receive a cardiac medication. Which is the nurse most likely to administer? 1. A decreased dosage 2. The standard dosage 3. An increased dosage 4. Divided dosages

1. A decreased dosage Rationale: Due to renal insufficiency, the dose of the medication would need to be decreased in order to avoid accumulation of the medication and the risk of toxicity.

The nurse is to administer a tuberculin test to a client who is 6 feet tall and weighs 180 pounds. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 2-mL syringe, #25 gauge, 5/8-inch needle 4. 2-mL syringe, #20-#23 gauge, 1-inch needle

1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle Rationale: A tuberculin test is given by intradermal injection. A tuberculin syringe is used because the dosage will most likely be 0.1 mL. A short, fine needle is needed to avoid entering the subcutaneous tissue. The needle should have a short bevel and usually be between #25 and #27 gauge. The needle should be between 1/4 to 5/8 inch long.

A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first? 1. Activate the fire alarm 2. Unplug the toaster from the wall 3. Put out the fire with an extinguisher 4. Evacuate the clients from the room next to the kitchen

1. Activate the fire alarm

The nurse knows and understands that a drug that produces the same type of response as the physiological or endogenous substance is called a(an): 1. Agonist 2. Antagonist 3. Receptor 4. Biotransformation

1. Agonist

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning 3. Falls 4. Poisoning

1. Automobile crashes Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use and becoming distracted while texting and using email. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

A nurse must administer a medication that is supplied in an ampule. Which should the nurse do first to access the ampule? 1. Break the constricted neck using a barrier 2. Wipe the constricted neck with an alcohol swab 3. Insert the needle into the center of the rubber seal 4. Inject the same amount of air as the fluid to be removed

1. Break the constricted neck using a barrier

A home care nurse is assigned to care for an older adult living at home. Which is the first action the home care nurse should empty to prevent falls by this older adult? 1. Conduct a comprehensive risk assessment 2. Encourage the client to remove throw rugs at home 3. Suggest illustration of adequate lighting throughout the home 4. Discuss with the client the expected changes of again that place one at risk

1. Conduct a comprehensive risk assessment

a client brings several electronic devices to a nursing home. one of the devices has a two-pronged plug. which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug? 1. Controls stray electrical currents 2. Promotes efficient use of electricity 3. Shuts off the appliance if there is an electrical surge 4. Divides the electricity among the appliances in the room

1. Controls stray electrical currents

A nurse plans to administer a 3-mL intramuscular injection. Which muscle is the least desirable to use for the administration of this medication? 1. Deltoid 2. Dorsogluteal 3. Ventrogluteal 4. Vastus lateralis

1. Deltoid

A nurse is preparing to draw up medication from a vial. Which action should the nurse implement first? 1. Ensure that the needle is firmly attached to the syringe 2. Rub vigorously back and forth over the rubber cap with an alcohol swab 3. Inject air into the vial with the needle bevel below the surface of the medication 4. Instill slightly more air than the volume of medication to be withdrawn from the vial

1. Ensure that the needle is firmly attached to the syringe

A nurse is preparing a client for a physical examination. Which is most important for the nurse to do in this situation? 1. Identify the positions contraindicated for the client during the examination 2. Explore the client's attribute toward health-care providers 3. Inquire about other professionals caring for the client 4. Ask when the client last had a physical examination

1. Identify the positions contraindicated for the client during the examination

A nurse is preparing to reconstitute a medication in a multiple-vial dose. Which is the most essential step in the preparation of this medication? 1. Instilling an accurate amount of diluent into the vial 2. Using a filtered needle when drawing up the medication from the vial 3. Instilling air into the vial before withdrawing the reconstituted needle 4. Wiping the rubber seal of the vial with alcohol before and after each needle insertion

1. Instilling an accurate amount of diluent into the vial

Which route is inappropriate for a topical medication? 1. Intradermal 2. Bladder 3. Rectum 4. Vagina

1. Intradermal

A nurse teaching a safety class for parents identifies the main causes of death for school-age children. Which of the following is NOT one of the leading causes? 1. Natural disasters 2. Fires 3. Drownings 4. Firearms

1. Natural disasters

A nurse is orienting a newly admitted client to the hospital. Which is the most important for the nurse to teach the client how to do? 1. Notify the nurse when help is needed 2. Get out of the bed to use the bathroom 3. Raise and lower the head and foot of the bed 4. Use the telephone system to call family members

1. Notify the nurse when help is needed

A primary health-care provider prescribes a vest restraint for a client. Which should the nurse do first when applying this restraint? 1. Perform an inspection of the client's skin where the restraint is to be placed. 2. Ensure that the back of the vest is positioned on the client's back 3. Permit four fingers to slide between the client and the restraint 4. Secure the restraint to the bed frame using a slip knot

1. Perform an inspection of the client's skin where the restraint is to be placed.

A nurse holds a bottle with the label next to the palm of the hand when pouring a liquid medication. What is the rationale for this action? 1. Prevent soiling of the label by spilled liquid 2. Conceal the label from the curiosity of others 3. Ensure accuracy of the measurement of the dose 4. Guarantee the label is read before pouring the liquid

1. Prevent soiling of the label by spilled liquid

A nurse who is planning care for a client requiring seizure precautions should plan to include which of the following? 1. Provide education to the client and family regarding the need to wear a medical identification tag 2. Assist the client in alerting all person in the community about their seizure disorder 3. Provide education regarding safety precautions for inside of the home only. 4. Discuss with the client, family, and person in the community factors that may precipitate a seizure

1. Provide education to the client and family regarding the need to wear a medical identification tag

Which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? 1. Providing adequate lighting 2. Raising the pitch of the voice 3. Holding onto the client's arm 4. Removing environmental hazards

1. Providing adequate lighting

Th nurse is performing an ear irrigation. Which nursing action is correct? 1. The nurse explains that the client may experience a feeling of fullness, warmth, and occasionally, discomfort when the fluid comes in contact with the tympanic membrane 2. The nurse angles the ear canal prior to inserting the tip of the syringe into the auditory meatus 3. The nurse pushes the solution gently downward against the bottom of the canal 4. The nurse places a cotton-tipped applicator in the auditory meatus

1. The nurse explains that the client may experience a feeling of fullness, warmth, and occasionally, discomfort when the fluid comes in contact with the tympanic membrane

When the nurse brings a pill to a client, the client is unable to hold the paper cup with the medication. Which should the nurse do? 1. Use the cup to introduce the pill into the client's mouth 2. Crush the pill and mix it with a small amount of applesauce 3. Have a primary health-care provider prescribe the liquid form of the drug 4. Put the pill into the client's hand and have the client self-administer the pill

1. Use the cup to introduce the pill into the client's mouth

A nurse must administer a medication into the ear of an adult. Which should the nurse do to limit client discomfort when administering the eardrum? 1. Warm the solution to body temperature 2. Place the client in a comfortable position 3. Pull the pinna of the ear upward and backward 4. Instill the fluid in the center of the auditory canal

1. Warm the solution to body temperature

The nurse is preparing a Compazine injection to be given to a client. Which of the following statements is correct? 1. When handling a syringe, the nurse may touch the outside of the barrel and the handle of the plunger 2. The nurse may touch the tip of the barrel with an unsterile object 3. The nurse may touch the shaft of the plunger with an unsterile object 4. The nurse may touch the tip of the needle with an unsterilized objet

1. When handling a syringe, the nurse may touch the outside of the barrel and the handle of the plunger

Which interventions should a nurse implement when assisting a client to use a bedpan? Select all that apply. 1. Ensure that the bed rails are raised after the client is on the bedpan 2. Position the rounded rim of the bedpan under the client's buttocks 3. Encourage the client to help as much as possible 4. Raise the head of the bed to the semi-Fowler position 5. Dust talcum powder on the rim of the bedpan before placing the bedpan under the client

2, 3, and 4

A provider prescribes a liquid oral medication for a client. Which action should the nurse implement when administering this medication? 1. Vigorously shake the liquid before pouring a dose 2. Measure oral liquids in a calibrated medication cup at eye level 3. Pour liquids with the label facing away from the palm of the hand 4. Place an opened top of a container on a surface with the inside facing up 5. Use a needless syringe to measure an oral liquid then transfer it to a medicine cup

2, 4, and 5

Which human response to illness alerts the nurse that a client is at risk for aspiration during meals? Select all that apply. 1. Bulimia 2. Lethargy 3. Anorexia 4. Stomatitis 5. Dysphagia

2, 4, and 5

A nurse is assessing a client to determine if it is appropriate to administer a prescribed medication via the oral route. Which information indicates that the nurse should ask the primary health-care provider for a change in route? Select all that apply 1. Nausea 2. Unconsciousness 3. Gastric suctioning 4. Emergency situation 5. Difficulty swallowing

2, and 4

Which intervention is uniquely related to the administration of an intradermal injection? Select all that apply 1. Using the air-bubble technique 2. Circling the injection site with a pen 3. Pinching the skin during needle insertion 4. Inserting the needle with the bevel upward 5. Massaging the area after the fluid is instilled

2, and 4

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1. Place a padded tongue depressor at the head of the bed 2. Pad the bed with blankets 3. Inform the client about the importance of wearing a medical identification tag 4. Teach the client about epilepsy 5. Test oral su

2, and 5 Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy.

A client tells the nurse, "This pill is a different color than the one that I usually take at home." Which is the best response by the nurse? 1. "Go ahead and take your medicine." 2. "I will recheck your medication orders." 3. "Maybe the doctor ordered a different medication." 4. "I'll leave the pill here while I check with the doctor."

2. "I will recheck your medication orders." Rationale: f there is any doubt, the medication administration process should be interrupted until the question is clarified. Listen to the client. Find out any other information the client may have about that certain medication. For example, does he know the dosage of the medication taken at home? Do not administer the medication (option 1). Inform the client that you will check the chart first. Review the chart to make sure there is no discrepancy between the physician's order and the MAR. Review the physician's progress notes because the medication may have been increased or reduced as part of the treatment plan (option 3). Check with the pharmacist because sometimes a pill may be a different color or shape based on the pharmaceutical company. Do not leave medications at the bedside. Medications should never be left unattended (option 4). Inform the client of your findings. The client will appreciate that you took the time to make

When evaluating a client's understanding of administering a vaginal foam, which of the following statements indicates a need for further teaching? 1. "I will gently insert the applicator into the vagina about 5 cm (2 in). 2. "I will remain lying in the supine position for 2 minutes following the insertion of the vaginal foam." 3. "I will slowly push the plunger of the applicator until the applicator is empty." 4. "I will discard the applicator is its is a disposable type."

2. "I will remain lying in the supine position for 2 minutes following the insertion of the vaginal foam."

A nurse teaches a client about taking a sublingual nitroglycerin tablet. Which part of the body identified by the client indicates that the client understands the teaching? 1. "On my skin." 2. "Inside my cheek." 3. "Under my tongue." 4. "In my eye on the lower lid."

2. "Inside my cheek."

Which should the nurse use when administering a subcutaneous injection? 1. 5-mL syringe 2. 25-guage needle 3. Tuberculin syringe 4. 1 1/2-inch long needle

2. 25-guage needle

A client weighs 110 lb. What is the correct kilogram amount a nurse should calculate is he or she understands how to convert pounds to kilograms? 1. 25 kg 2. 50 kg 3. 75 kg 4. 100 kg

2. 50 kg

A nurse is caring for a client with Parkison's disease who is experiencing difficulty swallowing. For which major potential problem associated with dysphagia should the nurse assess the client? 1. Anorexia 2. Aspiration 3. Self-care deficit 4. Inadequate intake

2. Aspiration

A nurse is preparing a seminar on drug misuse. Which of the following describes a mild form of psychological dependence, where the individual develops the habit of taking the substance and feels better after taking it, and the individual tends to continue the habit even though it may be injurious to health? 1. Drug dependence 2. Drug habituation 3. Physiological dependence 4. Psychological dependence

2. Drug habituation

A nurse plans to administer a bolus dose of a medication via a currently running IV infusion. Which should the nurse do first? 1. Use a volume-control infusion set with micro drip tubing. 2. Ensure that it is compatible with the IV infusion being infused 3. Pinch the tubing above the infusion port while instilling the bolus 4. Instill it into a 50-mL bag of normal saline and infuse it via a secondary line

2. Ensure that it is compatible with the IV infusion being infused

A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important? 1. Placing the client's name on the end of the bed 2. Ensuring that the bed wheels are locked 3. Positioning the call bell in reach 4. Raising one side rail

2. Ensuring that the bed wheels are locked

Which is the priority nursing intervention to prevent client problems associated with latex allergies? 1. Use non latex gloves 2. Identify persons at risk 3. Keep a latex-safe supply cart available 4. Administer an antihistamine prophylactically

2. Identify persons at risk

A nurse must reconstitute a powdered medication. Which action should the nurse implement? 1. Keep the needle below the initial fluid level as the rest of the fluid is injected 2. Instill the solvent that is consistent with the manufacturer's directions 3. Score the neck of the ampule before breaking it 4. Shake the vial to dissolve the powder

2. Instill the solvent that is consistent with the manufacturer's directions

Which information about a parenteral medication indicates that the nurse should use a filtered needle when preparing the medication? 1. Has to be reconstituted 2. Is supplied in an ampule 3. Appears cloudy in the vial 4. is to be mixed with another medication

2. Is supplied in an ampule

A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action take priority? 1. Discontinuing the wall suction when providing nursing care 2. Positioning the client in the semi-Fowler position 3. Instilling the tube with 30 mL of air every 2 hours 4. Caring for the nares at least every 8 hours

2. Positioning the client in the semi-Fowler position

Proper administration of an otic medication to a 2-year-old client includes which of the following? 1. Pull the ear straight back. 2. Pull the ear down and back. 3. Pull the ear up and back. 4. Pull the ear straight upward.

2. Pull the ear down and back Rationale: To straighten the ear canal in children less than 3 years of age, the ear must be pulled down and back. In individuals over 3 years of age, the ear is pulled up and back.

Which action should be implemented by the nurse when a medication is delivered by the Z-track method? 1. Use a special syringe designed for Z-track injections 2. Pull the skin laterally away from the injection site before administering the needle 3. Administer the injection in the muscle on the anterolateral aspect of the thigh 4. Insert the needle in a spirit spot for each doe on a Z-shaped grid on the abdomen

2. Pull the skin laterally away from the injection site before administering the needle

A school nurse is teaching children bout fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire? 1. Yell for help 2. Roll on the ground 3. Take their clothes off 4. Pour water on their clothes

2. Roll on the ground

An unconscious client begins vomiting. In which position should the nurse place the client? 1. Supine 2. Side-lying 3. Orthopneic 4. Low-Fowler

2. Side-lying

Suicide and homicide are two leading causes of death among teenagers. When planning a workshop on adolescent suicide and homicide, the nurse knows that which of the following is NOT among the most common factors influencing the high suicide and homicide rates? 1. Economic deprivation 2. Strong emotions toward friendships 3. Availability of firearms 4. Family breakup

2. Strong emotions toward friendships

A nurse planning a safety instruction class for parents of adolescents knows that the focus of the class should be on: 1. Teaching adolescents to sleep on a low bed 2. Teaching adolescents about driver safety 3. Teaching adolescents not to ingest lead paint chips 4. Teaching adolescents not to run or ride a tricycle into the street.

2. Teaching adolescents about driver safety

Which of the following actions by the nurse indicates that the nurse needs further instruction on the nursing assessment prior to applying restraints on a client? 1. The nurse checks the status of skin to which a restraint is to be applied 2. The nurse checks the circulatory status proximal to restraints 3. The nurse takes consideration of other protective measures that may be implemented before applying a restraint 4. The nurse determines underlying cause for assessed behavior

2. The nurse checks the circulatory status proximal to restraints

How often should "decussate sodium 100 mg PO bid" be given? 1. Three times a day 2. Two times a day 3. Every other day 4. At bedtime

2. Two times a day

A nurse is preparing to administer a tablet to a client. When should the nurse remove the medication from its unit dose package? 1. Outside the door to the client's room 2. When next to the client's bed 3. In the medication room 4. At the medication cart

2. When next to the client's bed

Which abbreviation indicates that the primary health care provider wants a medication administered before meals? 1. pc 2. ac 3. PO 4. OD

2. ac

A primary health-care provider prescribes a medication via a transdermal patch. Place the following steps in the order which they should be implemented when administering this medication 1. Remove the previous patch 2. Contain and dispose of the used patch 3. Wear clean gloves throughout the procedure 4. Write the date, time, and your initials on the patch 5. Apply a new patch to a different section of the skin 6. Wash and dry the skin after removal of the used patch

3, 1, 2, 6, 5, and 4

A nursing student is preparing to administer insulin to a client with diabetes. Indicate the correct order for the administration of this medication: 1. Cleanse the site with alcohol. 2. Insert the needle quickly into the subcutaneous tissue. 3. Mix the insulins. 4. Assess the skin for the injection. 5. Pinch the skin lightly. 6. Inject the medication. 7. Count to five. 8. Remove the syringe.

3, 4, 1, 5, 2, 6, 7, and 8 Rationale: This is the correct order for this skill—first the nurse mixes the insulin, assesses the skin, and cleanses the skin. The nurse would then pinch the skin, insert the needle, inject the medication, count to five, and remove the syringe.

When planning a safety in-service program for an independent living community for older adults, the nurse will include information on which of the following as the leading causes of injury among older adults? Select all that apply. 1. Firearms 2. Drownings 3. Suicide 4. Falls 5. Natural disaster

3, and 4

A primary health-care provider prescribes a liquid medication that has an unpleasant taste for a school-age child. What should the nurse do to facilitate administration of this medication? Select all that apply. 1. Mix it with the child's favorite food 2. Teach that the taste only lasts a short time 3. Give an ice pop just before giving the medication 4. Have a parent administer the medication if present 5. Offer the child the choice of a spoon, needless syringe, or dropper

3, and 5

A nurse instructs a client to inhale deeply and hold each breath for a second when using a hand-held nebulizer. The client asks, "Why do I have to hold my breath?" Which information should the nurse include in the response to the client's question? 1. "It prolongs treatment." 2. "It limits hyperventilating." 3. "It disperses the medication." 4. "It prevents bronchial spasms."

3. "It disperses the medication."

The nurse is to administer 0.75 mL of medication subcutaneously in the upper arm to a 300-pound adult client. The nurse can grasp approximately 2 inches of the client's tissue at the upper arm. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 3.2-mL syringe, #25 gauge, 5/8-inch needle 4. 4.2-mL syringe, #20-#23 gauge, 1-inch needle

3. 3.2-mL syringe, #25 gauge, 5/8-inch needle Rationale: Five milliliters is too large an amount to inject into one site. The nurse needs to divide the amount into two 2.5-mL injections. A 3-mL syringe could be used (option 1). The length of the needle will depend on the muscle development of the client. The nurse needs to assess the client. The presumption, based on the information provided, is that this client's muscle mass is within normal limits. The needle length would need to be 1 1/2 inches because the medication is be given "deep IM" (option 5). This also suggests that the medication should be given in the preferred site for IM injections—the ventrogluteal site—because it provides the greatest thickness of gluteal muscle. The gauge of the needle for an IM injection into the ventrogluteal muscle can range between #20 and #23 (option 3). The nurse needs to assess the viscosity of the medication. Smaller gauges (e.g., #23) produce less tissue trauma; however, viscous so

A primary health-care provider prescribes a medication that must be administered transdermally. Which information about the route of administration does the nurse understand is related to a drug prescribed to be administered transdermally? 1. Inhaled into the respiratory tract 2. Dissolved under the tongue 3. Absorbed through the skin 4. Inserted into the rectum

3. Absorbed through the skin

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program? 1. Wet floors 2. Frequent seizures 3. Advanced age of clients 4. Misuse of equipment by nurses

3. Advanced age of clients

A client has a prescription for a vaginal cream. Which should the nurse use when placing the cream into the client's vaginal canal? 1. A finger 2. A guaze pad 3. An applicator 4. An irrigation kit

3. An applicator

Which should the nurse do to best prevent a client from falling? 1. Provide a cane 2. Keep walkways clear of obstacles 3. Assist the client with ambulation 4. Encourage the client to use hallway handrails

3. Assist the client with ambulation

A nurse instructs a client to close the eyes gently after the administration of eyedrops. Which rationale for this instruction should the nurse explain to the client? 1. Limits corneal irritation 2. Forces excess medication from the eyes 3. Disperses the medication over the eyeballs 4. Prevents medication from entering the lacrimal duct

3. Disperses the medication over the eyeballs

A 3-year-old child is admitted to the pediatric unit. Which should the nurse do to maintain safety of this preschool-age child? 1. Teach the client how to use the call bell 2. Put the child in a crib with high side rails 3. Ensure the child is under continuous supervision 4. Have the child stay in the playroom most of the day

3. Ensure the child is under continuous supervision

A nursing is planning care for a client with a writes restrain. How often should a restraint be removed, the area massaged, and the joints moved through their full range? 1. Once a shift 2. Once an hour 3. Every 2 hours 4. Every 4 hours

3. Every 2 hours

When planning to teach healthcare topics to a group of male adolescents, which topic should the nurse consider a priority? 1. Sports contribute to an adolescent's self-esteem. 2. Sunbathing and tanning beds can be dangerous. 3. Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3. Guns are the most frequently used weapon for adolescent suicide. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.

A nurse is evaluating a nursing student's transdermal patch application to a comatose client. Which of the following actions demonstrates a need for further teaching? The student: 1. Selects a clean, dry area that is free of hair 2. Removes the patch from its protective covering 3. Holds the patch by touching the adhesive edges 4. Applies the patch by pressing firmly with the palm of the hand for about 10 seconds.

3. Holds the patch by touching the adhesive edges

A home-care nurse observes the spouse of a client inserting a rectal suppository into the client. Which behavior indicates that the nurse must provide further teaching about suppository administration? 1. Lubricates the tip of the suppository 2. Inserts the suppository while wearing a glove 3. Inserts the suppository while the client bears down 4. Places the suppository a finger length into the rectum

3. Inserts the suppository while the client bears down

A nurse is preparing a subcutaneous injection. Which muscle site should the nurse use to best promote its absorption? 1. Upper lateral arms 2. Anterior thighs 3. Love handles 4. Upper chest

3. Love handles

Which is the last step in making an occupied bed that the nurse should teach a nursing assistant? 1. Elevating the head of the bed to a semi-Fowler position 2. Ensuring that the client us in a comfortable position 3. Lowering the height of the bed toward the floor 4. Raising both the upper side rails on the bed

3. Lowering the height of the bed toward the floor

Which of the following would NOT be a preventive measure for an older client with poor vision? 1. Ensure eyeglasses are functional 2. Ensure appropriate lighting 3. Mark doorways only 4. Keep the environment tidy

3. Mark doorways only

The primary health-care provider prescribes a troche. In which part of the body should the nurse administer the troche? 1. Ear 2. Eye 3. Mouth 4. Rectum

3. Mouth

Profuse smoking is coming out of the heating unit in the patient's room. What should you do first? 1. Open a window 2. Activate the fire alarm 3. Move the patient out of the room 4. Close the door to the patient's room

3. Move the patient out of the room

A mother and her 3-year-old live in a home built in 1972. Which nursing diagnosis is most applicable for this child? 1. Potential for suffocation 2. Potential for injury 3. Potential for poisoning 4. Potential for decline in health

3. Potential for poisoning Rationale: A home that was built prior to 1978 has lead-based paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is potential for poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint.

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? 1. Report the fire. 2. Extinguish the fire. 3. Protect the clients. 4. Contain the fire.

3. Protect the clients. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine the fire, and extinguish the fire.

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1. Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3. Provide a bedside commode. 4. Keep the side rails up.

3. Provide a bedside commode Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

A client has a prescription for an analgesic. Which nursing action is appropriate when administering this medication? 1. Reassess drug effectiveness every 8 hours 2. Follow the prescription exactly for the first 24 hours 3. Seek a new prescription after two doses that do not achieve a tolerable level of relief 4. Ask the primary health-care provider to prescribe another medication for breakthrough pain

3. Seek a new prescription after two doses that do not achieve a tolerable level of relief

A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury? 1. Weakness experienced during a prior admission 2. Medication that increases intestinal mobility 3. Two recent falls that occurred at home 4. The need for corrective eyeglasses

3. Two recent falls that occurred at home

Which route is associated with the administration of a suppository? Select all that apply 1. Ear 2. Nose 3. Mouth 4. Vagina 5. Rectum

4, and 5

When evaluating a parent's understanding of safety measures for an infant, which of the following statements indicates a need for further teaching? 1. "I will store all household chemicals in the garage." 2. "I will make sure my infant is in his car seat before starting the care." 3. "I will keep small crafting beads locked in the cabinet." 4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."

4. "I will keep the trash bags in the kitchen on the bottom shelf by the sink."

A nurse is administering an intradermal injection. At which angle should the nurse insert the needle? 1. 90-degree angle 2. 45-degree angle 3. 30-degree angle 4. 15-degree angle

4. 15-degree angle

The nurse is to administer 0.5 mL of a medication by intramuscular injection to an older emaciated client. Which is the most appropriate for the nurse to use? 1. A tuberculin syringe, #25-#27 gauge, 1/4- to 5/8-inch needle 2. Two 3-mL syringes, #20-#23 gauge, 1 1/2-inch needle 3. 2-mL syringe, #25 gauge, 5/8-inch needle 4. 2-mL syringe, #20-#23 gauge, 1-inch needle

4. 2-mL syringe, #20-#23 gauge, 1-inch needle Rationale: If the nurse goes by the amount of the medication (0.5 mL) only, the deltoid muscle would be the site. However, knowing and assessing the client is critical. The muscles of an older, emaciated client will most likely be diminished or atrophied. The nurse should consider the ventrogluteal site because that site will have the most muscle mass.

Which characteristic is associated with a subcutaneous injection of 5,000 units of heparin. 1. 3-mL syringe 2. 22-guage needle 3. 1 1/2-inch needle length 4. 90-degree angle of insertion

4. 90-degree angle of insertion

A client with dysphagia. Which nursing action takes priority when feeding this client? 1. Ensuring that dentures are in place 2. Medicating for pain before providing meals 3. Providing verbal cueing to swallow each bite 4. Checking the mouth for emptying between every bite

4. Checking the mouth for emptying between every bite

The following medications are listed on a client's medication administration record (MAR). Which medication order should the nurse question? 1. Lasix 40 mg, po, STAT 2. Ampicillin 500 mg, q6h, IVPB 3. Humulin L (Lente) insulin 36 units, subcutaneously, every morning before breakfast 4. Codeine q4-6h, po, prn for pain

4. Codeine q4-6h, po, prn for pain Rationale: Options 1, 2, and 3 are written appropriately. Option 4 is incorrect because the dosage is missing from this order.

A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury? 1. School-age child 2. Comatose teenager 3. Postmenopausal woman 4. Confused middle-age man

4. Confused middle-age man

A primary health-care provider prescribes a medication that must be administered via the intramuscular route. Which site should the nurse eliminate from consideration because it has the highest potential for injury when administering an intramuscular injection? 1. Vastus lateralis 2. Rectus femoralis 3. Ventrogluteal 4. Dorsogluteal

4. Dorsogluteal

A primary health-care provider prescribes a medicated powder to be applied to a client's lower leg. Which is most essential for the nurse to do when applying the medicated powder? 1. Apply a thin layer in the direction of hair growth 2. Protect the client's face with a small towel 3. Dress the area with dry sterile guaze 4. Ensure that the skin surface is dry

4. Ensure that the skin surface is dry

A nurse in the nursing education department of a community hospital is planning an inservice education class about injury prevention. Which factor that most commonly causes injuries in hospitalized patients should be included in the teaching plan? 1. Malfunctioning equipment 2. Failure to use restraints 3. Visitors 4. Falls

4. Falls

A client in the emergency department is to receive a rectal suppository. Which of the following nursing actions is NOT correct for administering a rectal suppository? 1. The client can be placed in the left Sims' position 2. The smooth, rounded end of the rectal suppository is lubricated 3. After inserting the rectal suppository, press the client's buttocks together for a few minutes 4. Have the client remain in the left lateral position for 1 minute to help retain the suppository

4. Have the client remain in the left lateral position for 1 minute to help retain the suppository

Which should the nurse do to limit discomfort when administering an injection to an adult? 1. Pull back on the plunger before injecting the medication 2. Apply ice to the area before the injection 3. Pinch the area while inserting the needle 4. Inject the medication slowly

4. Inject the medication slowly

A nurse must apply a hospital gown to a client receiving an IV infusion in the forearm. Which should the nurse do? 1. Put the gown on the client's arm without the IV, and adjust the closure behind the neck 2. Close the clamp on the IV tubing for no more than 15 seconds while putting the gown on the client 3. Disconnect the client's IV at the insertion site, apply the gown, and then reconnect the IV 4. Insert the client's IV bag and tubing through the sleeve from inside of the gown first.

4. Insert the client's IV bag and tubing through the sleeve from inside of the gown first.

A home-care nurse is helping a client with short-term memory loss with how to remember to take multiple drugs throughout the day. Which should the nurse do when teaching this client? 1. Suggest the client wear a watch with an alarm 2. Ask a family member to call the client when medications are to be taken 3. Design a chart of the medications the client takes each day during the week 4. Instruct the client to put medications in a weekly organized pill container

4. Instruct the client to put medications in a weekly organized pill container

A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling? 1. Encourage the client to use the corridor handrails 2. Place the client in a room near the nurse's station 3. Reinforce how to use the call bell 4. Maintain close supervision

4. Maintain close supervision

A nurse is caring for a client with dementia. Which time of the day is of most concern of the nurse when trying to protect this client from injury? 1. Afternoon 2. Morning 3. Evening 4. Night

4. Night

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1. Keep all the side rails up. 2. Review prescribed medications. 3. Assess for fall risk on admission. 4. Place the bed in the lowest position.

4. Place the bed in the lowest position Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of a bed that is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Also, all side rails up is considered a restraint. Option 2 is important to do as certain medications can increase the risk of falling; however, this is not the best answer because it is not applicable to all clients. Option 3 helps the nurse assess a client's risk for falling but would not prevent injury.

A family member brings an electric radio to a client in a long-term facility. The client tells the nurse that an electric shock was felt while turning on the radio. Which should the nurse do? 1. Arrange for the maintenance to examine the radio 2. Disconnect the radio from the source of energy 3. Check the client's skin for electrical burns 4. Take the client's apical pulse

4. Take the client's apical pulse

A 75-year-old client, hospitalized with a stroke, becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1. Restrain the client in bed. 2. Ask a family member to stay with the client. 3. Check the client every 15 minutes. 4. Use a bed exit safety monitoring device.

4. Use a bed exit safety monitoring device. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate because the client could fall during the unobserved interval and it is not a realistic answer for the nurse.

Which action should the nurse implement when administering an intramuscular injection into the ventrogluteal site? Select all that apply. 1. Use a 1-inch needle 2. Use a 25-guage needle 3. Insert the needle at a 45-degree angle 4. Aspirate before instilling the medication 5. Massage the insertion site after needle removal

5

A health-care provider prescribes ear drops. Place the following steps in which they should be implemented. 1. Release the pinna and gently press on the tragus several times 2. Pull up and back on the pinna gently 3. Place the drops on the side of the ear canal without touching the canal with the dropper 4. Position the client in the side-lying position with the affected ear facing toward the ceiling 5. Warm the refrigerated eardrops to room temperature in the palm of your hand

5, 4, 2, 3, and 1