Medication and I.V. Administration - ML8

The nurse teaches a client taking desmopressin nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when the client makes which comment? "I should check for sores in my nose while taking this medication." "I should use the same nostril each time I take the medicine." "I should report any signs of respiratory infection." "I should report nasal congestion."

"I should use the same nostril each time I take the medicine." The client who is taking desmopressin nasal spray should not use the same nares for administration each time. The client should alternate nares every dose. The client should observe for and report promptly signs and symptoms of nasal ulceration, congestion, or respiratory infection.

When the nurse is preparing a teaching plan for an adult client about general anesthesia induction, which explanation by the nurse would be most appropriate? "You will breathe in medication through a facial mask to make you sleepy." "You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy." "You will receive intravenous medication to make you sleepy." "Your premedication will put you to sleep."

"You will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy." Adult clients are induced for general anesthesia by breathing in an inhalant anesthetic mixed with oxygen through a facial mask and receiving intravenous medication to make them sleepy. Clients are not induced with the premedication. Clients usually are not induced with the intravenous infusion or the mask alone.

A physician orders a soap suds enema, 500 ml. What does this amount equal in liters? 2 L 0.75 L 0.5 L 1 L

0.5 L 500 ml equals 0.5 L.

A client who weighs 207 lb (94.1 kg) is to receive 1.5 mg/kg of gentamicin sulfate IV three times each day. How many milligrams of medication should the nurse administer for each dose? Round to the nearest whole number.

141 Each of the 3 daily doses is 1.5 mg/kg. The client weighs 94.1 kg. Multiply 1.5 mg/kg/dose × 94.1 kg = 141.15 mg/dose, which rounds to 141 mg/dose.

The nurse needs to administer verapamil 0.3 mg/kg I.V. once a day to a pediatric client who weighs 20 lb (9.07 kg). The dose on hand is 5 mg/2 ml. How many milliliters will the nurse administer to the pediatric client? Round to the nearest tenth.

1.1 (0.3 mg / kg) x (2 ml / 5 mg) x (9.07 kg) = 1.09 mL = 1.1 ml The mg cancel out. The kg cancel out. Multiply 0.3 x 2 x 9.07 = 5.44 Divide 5.44 / 5 = 1. 09 and rounds to nearest tenth 1.1 ml

A physician orders preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed this way: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer? 3.8 ml 5 ml 2.5 ml 2 ml

2.5 ml Using the proportion method, the nurse solves for X and then adds the total number of milliliters together.

A client is to receive 1 unit of packed red blood cells over 2 hours. There are 250 mL in the infusion bag. The IV administration infusion set delivers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse run the infusion? Record your answer using a whole number.

21 One unit of packed red blood cells contains 250 mL, and this is to infuse over 2 hours (120 minutes). First, determine the number of mL/minute by dividing 250 mL by 120 minutes: 250 mL/120 min = 2.1 mL/min. Then multiply by the drop factor of 10 gtt/mL: 2.1 mL/min × 10 gtt/mL = 21 gtt/min.

The nurse is preparing 1,000 mL D5/N5 to deliver over 6 hours. If the infusion set administers 15 gtt/mL, what is the required flow rate in gtt/min? (Round to the nearest whole number.)

42 The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtt/mL × 1,000 mL/6 h x 1 h/60 min = 42 gtt/min.

The health care provider (HCP) has prescribed guaifenesin 300 mg four times a day. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using one decimal place.

7.5 300 mg/X = 200 mg/5 mL X = 7.5 mL.

The nurse is obtaining blood from a central venous access device (CVAD) using aseptic technique and during the procedure soils the CVAD dressing with blood. After the sample is obtained and sent to the laboratory, what should the nurse do next? Change the soiled dressing per facility policy. Call the health care provider regarding contamination of the CVAD dressing. Redraw the specimen from the CVAD using sterile technique. Reinforce the CVAD dressing.

Change the soiled dressing per facility policy. CVADs are used to obtain blood samples. Any dressing that is damp, loose, or soiled should be changed immediately and not just reinforced. Sterile procedure is not used for accessing CVADs, and the health care provider does not need to be called.

The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. The nurse notes that the muscle is quivering as landmarks are assessed. How should the nurse respond? Have the client lie supine and flex the foot. Have the client lie on the left side. Choose another site for injection. Distract the client during the injection.

Choose another site for injection. The nurse should never inject into sensitive muscles, especially those that twitch or tremble during assessment of site landmarks and tissue depth. Injections into these trigger areas may cause sharp or referred pain, such as the pain caused by nerve trauma. Positioning the client supine and flexing the foot is correct for the injection site, but ignores the assessment findings. Positioning the client on the left or right side would allow access to the ventrogluteal site. Distraction also ignores the assessment finding.

The physician has prescribed amiodarone for a client with cardiomyopathy. The nurse should monitor the client's rhythm to determine the effectiveness of the medication in controlling: Sinus node dysfunction. Severe bradycardia. Life-threatening ventricular dysrhythmias. Heart block.

Life-threatening ventricular dysrhythmias. Cardiomyopathy means that the myocardium is weak and irritable. Amiodarone is an antiarrhythmic and acts directly on the cardiac cell membrane. In this situation, amiodarone is used to increase the ventricular fibrillation threshold. Amiodarone is contraindicated in sinus node dysfunction, heart block, and severe bradycardia.

The nurse understands that assessment of blood pressure in clients receiving antipsychotic drugs is important. What is a reason for this assessment? Orthostatic hypotension is a common side effect. This provides additional support for the client. It will indicate the need to institute antiparkinsonian drugs. Most antipsychotic drugs cause elevated blood pressure.

Orthostatic hypotension is a common side effect. Orthostatic hypotension is common during the first few weeks of treatment with antipsychotic drugs. An elevated blood pressure usually results from MAOI antidepressants. Additional support should be through therapeutic communications. A problem with the blood pressure is not indicative of antiparkinsonian drugs.

The nurse is assessing for blood return from a client's implanted port. Which nursing intervention is appropriate to assure that the needle will be flushed with pure saline? Wash hands before and after the procedure. Flush with heparin after drawing the sample. Draw the smallest amount of blood required for the sample. Prevent blood from entering the saline flush syringe.

Prevent blood from entering the saline flush syringe. To assure that the needle will be flushed with pure saline, the nurse does not allow blood to enter the saline flush syringe when assessing for blood return from an implanted port. Washing hands prevents contamination, drawing the least amount of blood prevents overwasting, and flushing with heparin prevents clots.

A client is to receive an IM injection using a Z-track injection technique. The nurse holds the gauze pledget against an IM injection site while removing the needle from the muscle. What is the intended outcome of this technique? Prevent organisms from entering the body through the skin puncture. Seal off the track left by the needle in the tissue. Speed the spread of the medication in the tissue. Avoid the discomfort of the needle pulling on the skin.

Seal off the track left by the needle in the tissue. When administering an injection using the Z track method, holding the gauze pledget against the site while removing the needle from the muscle helps to seal off the track left by the needle in the tissue.

When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion to the client? Take over-the-counter antiemetics. Exercise three to four times a week. Eat foods that are low in potassium. Take the prednisone with food.

Take the prednisone with food. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol? bone marrow suppression malignant hypertension status epilepticus lethal arrhythmias

bone marrow suppression The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol isn't known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

A client with major depressive disorder is receiving phenelzine. The nurse intervenes when the client orders which food for lunch? green beans yogurt with fruit pepperoni pizza Salisbury steak

pepperoni pizza Clients taking phenelzine, a monoamine oxidase inhibitor, cannot take foods with high tyramine content. Pepperoni is a sausage with a high tyramine content. Yogurt with fruit, Salisbury steak, and green beans have little or no tyramine.

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance? evidence of a bleb tissue pallor minimal leaking no swelling

evidence of a bleb A properly administered intradermal injection shows evidence of a bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.

The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client? walking stretching running floor exercises

walking The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.

Which statement made by a client who is taking misoprostol indicates a therapeutic outcome of therapy? "My blood pressure is normal." "My heart doesn't beat as fast now." "My stomach feels better." "I can breathe easier."

"My stomach feels better." Misoprostol is used to protect the stomach's lining when a client has a peptic ulcer. Misoprostol does not affect the cardiac or respiratory systems.

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take? Start the 30-mg dose tomorrow. Discontinue the prednisolone 40 mg and give the 30-mg dose today. Contact the prescriber for clarification. Check the medication record first to see when the last dose of prednisolone was given.

Contact the prescriber for clarification. There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next, or even the day after that. The only safe thing to do is call for clarification.

While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first? Hang a new bag of D5W, and complete an incident report. Continue to monitor the bag of IV solution. Notify the health care provider (HCP). Ask another nurse to look at the solution.

Hang a new bag of D5W, and complete an incident report. Maintenance of IV sites and systems includes regular assessment and rotation of the site and periodic changes of the dressing, solution, and tubing; these measures help prevent complications. The nurse should also observe the solution for discoloration, turbidity, and particulates. An IV solution is changed every 24 hours or as needed, and because the nurse noted an abnormal color, the nurse should change the bag of D5W and note this on an incident report. It is not necessary to verify this action with another nurse. Paging the HCP is not necessary; maintaining the IV and using the correct solutions is a nursing responsibility. Although the first action is to hang a new bag, hospital policy should be followed if there is a question as to whether there could have been an unknown substance in the bag that caused it to change color.

A client, with systemic lupus erythematosus (SLE) has been on corticosteroid therapy for the last 2 years. The nurse should assess for what? Select all that apply. hyperpigmentation of the skin and itching hyponatremia and hypokalemia skeletal muscle atrophy and osteoporosis hyperglycemia and fluid retention hypoglycemia and cognitive changes

hyperglycemia and fluid retention skeletal muscle atrophy and osteoporosis Long-term corticosteroid administration results in significant changes. Two long-term effects of corticosteroid administration are muscle atrophy and osteoporosis. Hyperglycemia and fluid retention is another serious side effect that can occur, so clients must be monitored for edema. Hypoglycemia, hyponatremia, hypokalemia, and hyperpigmentation are not side effects of this category of medication.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison's crisis following surgery? prednisone orally methylprednisolone sodium succinate intravenously fludrocortisone subcutaneously spironolactone intramuscularly

methylprednisolone sodium succinate intravenously A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Spironolactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisones is a mineral corticoid.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? the client the pharmacist the risk manager the prescriber

the prescriber After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

The nurse is teaching the client with cirrhosis about taking lactulose. The nurse should tell the client that which type of bowel movement is an expected outcome of taking this drug? two to three soft stools per day one regular bowel movement a day four to five loose stools per day five to six loose stools per day

two to three soft stools per day The expected effect of lactulose is for the client to have two to three soft stools a day to help reduce the pH and serum ammonia levels, which will prevent hepatic encephalopathy. Diarrhea, or frequent loose stools, is a potential adverse effect of the medication.

The client's blood sugar is 210 mg/dL (11.7 mmol/L) this morning. The nurse verifies a dose of 8 units of regular insulin from the sliding scale. Which sites are acceptable for the nurse to administer the insulin? Select all that apply. deltoids inside forearms upper outer thighs upper outer arms abdomen

upper outer thighs upper outer arms abdomen For a subcutaneous injection of insulin, the nurse should pick from these areas with adipose tissue beneath the skin: upper outer thighs, upper outer arms, abdomen, or buttocks. The deltoids are an intramuscular area, and the inside forearm lacks a fatty pad beneath the skin.

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse? Repeat the vital signs in 1 hour. Slow the intravenous rate and notify the physician. Lower the head of the bed. Administer oxygen and encourage the client to breathe deeply.

Slow the intravenous rate and notify the physician. The increased volume from too-rapid fluid infusion will result in increased heart rate. There can be pulmonary edema with resultant increase in the respiratory rate to compensate. Jugular vein distension also indicates fluid overload. The rate of the intravenous fluids would need to be slowed, and the physician notified for new orders. Repeating the vital signs in 1 hour is incorrect because the client is already in distress. Lowering the head of the bed will increase the symptoms. Although oxygen may help, the priority is to decrease fluid volume.

The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about stopping the drug suddenly? A hypoglycemic reaction is likely. Status epilepticus may occur. Physical dependency develops over time. Heart block can happen.

Status epilepticus may occur. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The health care provider (HCP) has prescribed 2 units of packed red blood cells (RBCs). What should the nurse determine prior to initiating the blood transfusion? Select all that apply. There is a signed informed consent for transfusion therapy. The vital signs have been taken and documented in accordance with facility policy and procedure. The client has an identification bracelet. There is the second unit of blood in the medication room. There is an IV access with the appropriate tubing and normal saline as the priming solution. Blood typing and cross-matching are documented in the medical record.

There is an IV access with the appropriate tubing and normal saline as the priming solution. There is a signed informed consent for transfusion therapy. Blood typing and cross-matching are documented in the medical record. The vital signs have been taken and documented in accordance with facility policy and procedure. The client has an identification bracelet. Before prescribing and administering packed RBCs, the nurse should assess the IV site to make sure it has an 18G to 20G infusion set. The nurse should also ensure that normal saline solution is used to prime the tubing to prevent RBCs from adhering to the tubing. The client must indicate informed consent for the procedure by signing the consent form. The client's blood must be typed to determine ABO blood typing and Rh factor and ensure that the client receives compatible blood. Cross-matching is done to detect the presence of recipient antibodies to the donor's minor antigens. Vital signs provide a baseline reference for continuous monitoring throughout the transfusion. An identification bracelet and red blood band are essential for client identification per facility policy. Two nurses must double check the client's identification with the client listed on the unit of RBCs. The transfusion should be started within 30 minutes of the time that the RBC unit is checked out of the blood bank. Thus, no blood should be kept in the medication room before transfusion.

The nurse is administering 5,000 units heparin subcutaneously to a client. (See the accompanying image.) What step should the nurse include in administration? Deposit the heparin deep in the muscle. Insert the needle at a 30-degree angle. Aspirate prior to injecting the heparin. Use a shorter needle.

Use a shorter needle. Heparin should be administered into subcutaneous tissue at a 45-degree or 90-degree angle using a 27-gauge 5/8-inch (1.6-cm) needle. The medication should not be administered into the muscle. In order to prevent hematoma formation, the nurse should not rotate the tip of the needle or aspirate before injecting the heparin.

The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply. When discontinuing the I.V. When priming the I.V. tubing When spiking a new I.V. bag when inserting the I.V. When changing the I.V. site

When discontinuing the I.V. When inserting the I.V. When changing the I.V. site The nurse should wear protective gloves when inserting the I.V., when discontinuing the I.V., and when changing the I.V. site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution.

The nurse should instruct the client to avoid taking which drug while taking metoclopramide hydrochloride? central nervous system depressants antihypertensives antacids anticoagulants

central nervous system depressants Metoclopramide hydrochloride can cause sedation. Alcohol and other central nervous system depressants add to this sedation. A client who is taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug. Clients may take antacids, antihypertensives, and anticoagulants while on metoclopramide.

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant? hemoglobin level, hematocrit, and platelet count lee-White clotting time potassium level blood glucose level

hemoglobin level, hematocrit, and platelet count The baseline laboratory data that are established before a client is started on tissue plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome? less difficulty breathing suppression of the client's respiratory infection. thinning of tenacious, purulent sputum. decrease in bronchial secretions.

less difficulty breathing Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

A nurse must deliver 1,000 ml of normal saline solution over 8 hours. The I.V. tubing has a drop factor of 10 gtt/ml. The nurse should set the flow rate as 31 gtt/minute 21 gtt/minute 20.5 gtt/minute 25 gtt/minute

21 gtt/minute The nurse can use various methods to calculate the gtt/minute. One method is dividing the total volume by the total time in minutes, and multiplying that number by the drop factor. 8 X 60 minutes equals 480 minutes. 1,000 divided by 480 equals 2.08. 2.08 X 10 equals 20.8, which rounds to 21.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy? spasms of the diaphragm cough and shortness of breath decrease in appetite drowsiness

cough and shortness of breath Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate? diastolic blood pressure greater than 90 mm Hg respiratory rate of 20 breaths/minute urine output greater than 30 ml/hour systolic blood pressure greater than 110 mm Hg

urine output greater than 30 ml/hour Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

When administering an IM injection, when should the nurse use the Z-track technique? when the medication has a viscous consistency when the medication is irritating to tissues when the medication has a long absorption time when the medication takes effect very quickly

when the medication is irritating to tissues The Z-track technique is used with medications that are irritating to tissues. It allows the medication to be trapped in the muscle and prevents it from leaking back through the tissues.

Which statement indicates that a client understands discharge instructions about propranolol? "I will take this medication whenever I feel anxious." "I will assess my heart rate before I take my medication." "I will take this medication in the morning." "I will not take this medication if I see yellow halos around lights."

"I will assess my heart rate before I take my medication." The therapeutic effect of propranolol is to lower the heart rate. Generally, clients should assess and call their healthcare provider if their heart rate drops below 55 beats per minute. Yellow halos indicate digoxin toxicity. The time of day when this medication is taken does not matter. Propranolol is not used as a taken-as-needed medication for anxiety.

A client has been taking dexamethasone for 2 weeks. The nurse evaluates a client's knowledge as deficient when the client makes which comment? "When I get a cold, I need to let my health care provider know." "I can't stop the medication all at one time." "I need to watch for an allergic reaction when I first start taking this pill." "If I forget a dose, it's no big deal; I'll just take it when I remember it."

"If I forget a dose, it's no big deal; I'll just take it when I remember it." The statement "If I forget a dose, it's no big deal, I'll just take it when I remember it" indicates a knowledge deficit. The nurse should reinforce that the client should take dexamethasone as prescribed and at the same time each day. The drug has to be tapered off and cannot be stopped abruptly. The health care provider (HCP) should be notified when the client is under additional stress (e.g., infection, surgery, illness). The client can have an allergic reaction to inactive ingredients contained in dexamethasone.

A physician orders an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, a client should receive how many milliliters of I.V. fluid per hour? 50 ml/hour 100 ml/hour 240 ml/hour 120 ml/hour

120 ml/hour First, the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2,400 ml ÷ 2 = 1,200 ml. Then the nurse determines how many of these milliliters to deliver per hour: 1,200 ml ÷ 10 hours = 120 ml/hour.

The client in preterm labor is admitted to the hospital. To stop the client's uterine contractions, the nurse anticipates administering which medication? dinoprostone terbutaline ergovine maleate misoprostol

terbutaline Terbutaline is used to inhibit preterm uterine contractions. Dinoprostone and misoprostol are used to induce fetal expulsion and promote cervical dilation and effacement. Ergonovine maleate stops blood flow to the uterus and is used for hemorrhage.

Which is most critical for the nurse to communicate to the health care provider (HCP) prior to placing an epidural analgesia catheter? The client: consumed 240 mL of beef broth 4 hours prior. has had an indwelling urinary catheter in place for 2 days. received enoxaparin 40 mg subcutaneously 1 hour ago. has an albumin level of 3.5 g/dL.

received enoxaparin 40 mg subcutaneously 1 hour ago. Clients receiving anticoagulation are at high risk for an epidermal hematoma. If the client is taking any anticoagulants, this should be immediately relayed to the HCP scheduled to perform the procedure. Clear liquids may be limited 2 hours prior to the procedure, but this varies by HCP and institutional guidelines. The albumen level is on the lower end of normal and is not a concern. The indwelling urinary catheter is not a concern at this time.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? Clamp the catheter. Apply a dry sterile dressing to the site. Tell the client to take and hold a deep breath. Call the physician.

Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of [800 mg/dl (44.4 mmol/L)]. Which solution is the most appropriate at the beginning of therapy? 100 units of regular insulin in normal saline solution 100 units of regular insulin in dextrose 5% in water 100 units of NPH insulin in dextrose 5% in water 100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution

100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia.

The nurse must administer ferrous sulfate to an infant who weighs 8 lb 13 oz (4.00 kg). The dosage prescribed is 6 mg/kg/day to be given in three doses. What would be the correct amount to be administered for each dose? Record your answer using a whole number.

8 The client must receive 6 mg/kg/day over 3 doses/day. Therefore, divide 6 by 3 to find the per-dose rate: 2 mg/kg. Now multiply the medication per kilogram by the weight in kilograms: 2 mg/kg × 4 kg = 8 mg. The client should receive 8 mg of ferrous sulfate with each dose.

The nurse assesses a client who has just received morphine sulfate. The client's blood pressure is 90/50 mm Hg; pulse rate, 58 bpm; and respiration rate, 4 breaths/min. What should the nurse do first? Start oxygen at 2 liters/min per nasal cannula. Call the rapid response team. Administer naloxone hydrochloride. Obtain a stat ECG.

Administer naloxone hydrochloride. The nurse should first administer naloxone hydrochloride, which is the antidote for morphine sulfate. The signs of overdose on morphine sulfate are a respiration rate of 2 to 4 breaths/min, bradycardia, and hypotension. If the client does not respond, the nurse can call the rapid response team. The client's respirations should improve after receiving the naloxone. Obtaining an ECG is not the first priority for reversing the effects of the morphine.

The nurse is preparing to administer furosemide to a 3-year-old with a heart defect. After verifying the arm band, which is the most appropriate second identifier for the nurse to use? Ask the child to tell her birth date. Ask the parent the child's name. Ask the child to state her name. Check the room number.

Ask the parent the child's name. Safety standards require the use of two identifiers prior to medication administration. A parent can be used as the second identifier. Many young children will only answer to a nickname that does not coincide with the medical identification band, may not answer, or may answer to any name. It is common for children on a pediatric floor to go into each other's rooms. A small child may not know his or her birth date.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order? Ask if the client would prefer to have an enema administered. Ask the physician to prescribe a specific laxative. Give mineral oil because it does not require a physician's order. Ask what type of laxative the client would like to have.

Ask the physician to prescribe a specific laxative. The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

The nurse is preparing to administer an I.V. medication through a tunneled venous access device. Prior to administering an I.V. medication, the nurse meets resistance when attempting to flush the line with saline. What is the best action by the nurse? Assess for external blockage and/or clamping of the line. Obtain a larger syringe and attempt to flush the line. Administer heparin to declot the line. Inject alteplase to declot the line.

Assess for external blockage and/or clamping of the line. The best action by the nurse is to assess for external kinks and/or other exterior blockages of the line such as clamping of the line. Alteplase may be appropriate if the line is clotted but requires a physician's order and the nurse should first assess for external blockage. Heparin is utilized to maintain patency of the line after flushing or medication administration. Obtaining a larger syringe may increase the pressure of the flush and rupture the central line.

Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine? Drink 10 to 12 glasses of water each day. Eat a normal amount of salt in the diet. Avoid foods high in tyramine. Allow 10 days to achieve therapeutic effects.

Avoid foods high in tyramine. A client who is taking phenelzine, a monoamine oxidase inhibitor, needs to avoid foods that are rich in tyramine because this food-drug combination can cause hypertensive crisis. The client should be given a list of foods to avoid and should report headaches, palpitations, and a stiff neck to the health care provider (HCP) immediately. The client does not need to restrict or add salt to the diet. Drinking 10 to 12 glasses of water each day is important to teach the client who is receiving lithium therapy. Antidepressant drugs take 2 to 4 weeks to achieve therapeutic effects.

The client's health care provider prescribes buspirone hydrochloride for increased anxiety. The nurse understands the health care provider's choice of this medication is based on what principle? Buspirone is often administered on an as-needed basis. Buspirone is chemically similar to benzodiazepine medications. Buspirone is not habit forming. Buspirone does not have any drug side effects.

Buspirone is not habit forming. Buspirone is not habit forming, is administered on a schedule, and does not work immediately. Buspirone may have side effects such as chest pain, dizziness, headache, drowsiness, or nausea. Buspirone hydrochloride is not chemically or pharmacologically related to benzodiazepines or other sedative medications.

A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse? Call the physician to report the finding. Apply warm, moist heat to the right ankle area. Repeat the dose of analgesic every hour. Massage the client's foot in a circular motion.

Call the physician to report the finding. The best response would be to notify the physician. The nurse cannot repeat the dose of analgesic without an order. Massaging the ankle and applying moist heat would be inappropriate for a number of reasons. The client could be developing a deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing, and the physician should be made aware of the situation.

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice? Create a poster presentation on the topic with a required posttest. Post an evidence-based article on the unit. Send a group email discussing the importance of clamping the device first. Ask each nurse if they are aware that their practice is not current.

Create a poster presentation on the topic with a required posttest. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not assure that the information is read.

A client continually reports of pain after the administration of an oral analgesic. The physician writes an order for the nurse to administer a placebo to the client the next time the client reports of pain. The doctor states, "Tell the client it is a stronger analgesic." What would be the appropriate action by the nurse? Give the placebo as ordered by the physician. Consult with the pharmacist to discuss the dosage of the placebo. Give the placebo but do not tell the client it is a stronger medication. Refuse to administer the placebo to the client.

Refuse to administer the placebo to the client. The nurse should refuse to give the placebo and should also refuse to misinform the client. The nurse has a responsibility to explain the client's medications to the client. The client can then make an informed decision about accepting or refusing the medication. The other options are incorrect because the nurse would be misinforming the client about the medication that is being administered. The client would not be able to provide informed consent.

The health care provider (HCP) has prescribed nitroglycerin to a client with angina. The client also has closed-angle glaucoma. The nurse should contact the HCP to discuss the potential for which drug interaction? hypotension hypertension increased intraocular pressure decreased intraocular pressure

increased intraocular pressure Nitroglycerin causes vasodilation, which results in increased intraocular pressure. The vasodilatory effects of the medication can trigger an attack, causing pain and loss of vision. Hypotension is a common side effect of nitroglycerin, which dilates the blood vessels but is not a concern in the client with glaucoma.

The nurse has administered aminophylline to a client with emphysema. Which indicates the medication has been effective? stimulation of the medullary respiratory center relaxation of smooth muscles in the bronchioles efficient pulmonary circulation relief from spasms of the diaphragm

relaxation of smooth muscles in the bronchioles Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.

The student nurse is planning to care for a peripheral intravenous (I.V.) site for a client receiving chemotherapy. Which outcome would demonstrate that the student understands the concepts of I.V. care? Clean the insertion site and change the dressing every 72 hours. Periodically flush the catheter with heparin to maintain its flow of I.V. solution. Monitor for redness, drainage, and swelling at the insertion site every 24 hours. If extravasation is suspected, stop the infusion.

If extravasation is suspected, stop the infusion. Peripheral venous access devices are commonly used for clients receiving long-term chemotherapy, total parenteral nutrition, or frequent medication or fluids. These devices may remain in place for several weeks to more than 1 year if no complications develop. Extravasation, or infiltration of the drug into surrounding tissue, is an emergency, and the priority action is to stop the infusion. The site could be cleaned and dressing changed more often than every 72 hours depending on the type of dressing, patient's condition, and other factors. Heparin is not used to flush peripheral sites. Nurses monitor I.V. sites more frequently than every 24 hours; the site should be checked at least every 4 hours.

A client has been prescribed diuretic therapy for hypertension. It has been causing frequent urination at night and now the client is refusing to take the morning dose of furosemide. What would be the best response by the nurse? Take the blood pressure and then discuss with the client the dangers of an increased blood pressure if the medication is not taken. Reinforce how much the edema has decreased and how effective the medication has been, and encourage the client to take the medication. Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. Tell the client that the extra fluid will be gone and urination will not be as frequent.

Reinforce the reason for the medication. Respect the decision if the client still refuses the medication, and chart the refusal. The client needs to understand the importance of extra fluid removal and how it helps control blood pressure. The nurse needs to be respectful that the client still has a choice in whether to take the medication.

A client will receive IV midazolam hydrochloride during surgery. Which finding indicates a therapeutic effect? blurred vision mild agitation amnesia nausea

amnesia Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember events that occurred around the time of sedation. Nausea, mild agitation, and blurred vision are adverse effects of midazolam.

For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met? PaO2 of 70 mm Hg (9.31 kPa) respiratory rate of 26 breaths/min pain rating of 0 on a scale of 0 to 10 by the client decreased client anxiety

pain rating of 0 on a scale of 0 to 10 by the client If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/min is not within normal limits, nor is the PaO2 of 70 mm Hg (9.31 kPa), but these values are not measures of pain relief.

A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because "I am so worried about everything." Her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she's on aripiprazole, which was increased to 30 mg by her health care provider (HCP) 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which factors? Select all that apply. the dose of aripiprazole the client's symptoms of heart failure the client's symptoms of schizophrenia the qualifications of the client's HCP the client's relationship with her son

the dose of aripiprazole the client's symptoms of heart failure the client's symptoms of schizophrenia The client's symptoms are likely to be adverse effects of aripiprazole, especially at the reported dose. The normal adult dose is 5 to 10 mg. The older adult client commonly needs a lower dose compared with other adults. The anxiety and sleep disturbance could be symptoms of schizophrenia or medication adverse effects. A holistic approach would include assessing the client's heart failure. Questioning the qualifications of the family HCP is unproductive. There are no indications of problems in the client's relationship with her son.

A nurse manager notices that a number of medication errors have occurred on the unit with nurses giving hydralazine instead of hydroxyzine. What would be the most appropriate action for the nurse manager? Post the names of nurses making medication errors on a bulletin board. Consult with pharmacy to ensure distinct labeling of the medications. Provide an in-service on the differences between hydralazine and hydroxyzine. Require nurses to retrieve individual doses of the medications from the pharmacy.

Consult with pharmacy to ensure distinct labeling of the medications. Sometimes medication errors increase with drugs that are similar in name. These are sometimes referred to as SALAD names, which refer to sound-alike, look-alike drugs. The pharmacy should be consulted to help determine a way to label each medication that draws attention to the name of the medication.

A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should: question the prescription because gentamicin could cause further hearing impairment. question the prescription because gentamicin could cause further visual impairment. give the drug as prescribed. question whether the drug is appropriate for treatment of peritonitis.

question the prescription because gentamicin could cause further hearing impairment. Aminoglycoside antibiotics can cause damage to the eighth cranial nerve and result in ototoxicity. If the client is already hearing impaired, the nurse should question the prescription with the health care provider, who may determine that prescribing another antibiotic would be safer.Gentamicin is an appropriate antibiotic for gram-negative infections such as peritonitis.Gentamicin does not cause visual impairment.

An older adult is receiving morphine to manage pain after abdominal surgery. The nurse should observe the client for which side effect of this drug? constipation dysrhythmias seizures respiratory depression

respiratory depression It is especially important for the nurse to carefully assess the elderly client for respiratory depression after administering a dose of meperidine. It may be necessary to reduce the dosage to prevent respiratory depression. Dysrhythmias, constipation, and seizures are all potential adverse effects of meperidine, but respiratory depression is most significant in the elderly.

The physician has placed a client who has suffered the loss of a child on a selective serotonin reuptake inhibitor (SSRI) for depression. The nurse is aware that the greatest risk for suicide would be: once the client is discharged home with family. when the nurse sees the client visiting with other clients on the nursing unit. on the 1-year anniversary of the child's death. 10 to 14 days after the initial medication regime is implemented.

10 to 14 days after the initial medication regime is implemented. Ten to fourteen days is the normal response time for antidepressant medications to take effect and subsequent return of energy levels to perform the suicide act. There is no information about problems with the family that would precipitate suicide. The 1-year anniversary could be a stimulus, but a lower priority. Visiting with other clients is a positive interaction with elevation of mood.

A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, "That's not my pill! My pill is blue, not green." What should the nurse tell the client? "I'll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color." "Go ahead and take it. You can trust me. I'm watching out for your safety and well- being." "I know I took the correct medication out of the dispenser. Don't you trust me?" "Don't worry; your medication is generic, and sometimes the manufacturers change the color of the pills without letting us know."

"I'll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color." It is important for the nurse to listen to the client and respect his or her knowledge about the medication. In the other options, the nurse dismisses the client's concern or gives a possible explanation without checking out the specific situation. If the nurse has taken the wrong medication, the client can prevent a medication error, and if there has been a color change, the nurse can let the client know that information. In either case, helping a psychotic client deal with reality appropriately is therapeutic.

The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102° F (38.8° C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 ml. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.

20.3 This formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 160 mg/5 ml = 650 mg/X. Therefore, X = 20.3 ml.

Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed? "Infusion set administration connections should be tight." "Cytotoxic parenteral infusion containers should be marked with special hazard labels." "Linen contaminated with blood or body fluids of a client receiving cytotoxic drugs should be placed in a leak-proof container and marked with a chemotherapy hazard label." "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs."

"Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." Pregnant nurses should not administer cytotoxic drugs because long-term exposure to cytotoxic drugs may be associated with teratogenic effects. Nonpregnant nurses should wear double gloves and long sleeve disposable gowns while administering cytotoxic drugs. To prevent exposure and leakage, the nurse should mark all parenteral infusion containers with hazard labels and check infusion container connections before drug administration. Linens that have become contaminated by blood or body fluid of a client receiving chemotherapy should be handled with caution, placed in a leak-proof, closed system and labeled "chemotherapy contaminated linens."

The health care provider (HCP) is calling in a prescription for ampicillin for a neonate. What should the nurse do? Select all that apply. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse. Ask the HCP to confirm that the prescription is correct. Write down the prescription. Ask the HCP to come to the hospital and write the prescription on the medical record. Repeat the prescription to the HCP over the telephone.

Ask the HCP to confirm that the prescription is correct. Write down the prescription. Repeat the prescription to the HCP over the telephone. The nurse should write down the prescription, read the prescription back to the HCP, and receive confirmation from the provider that the prescription is correct as understood by the nurse. It is not necessary for the HCP to come to the hospital to write the prescription on the medical record or to have the nursing supervisor cosign the telephone prescription.

The health care provider's (HCP's) prescription for an intravenous infusion is 3% normal saline to infuse at 125 mL/h. The client's most recent sodium level is 132 mEq/L (132 mmol/L). What should the nurse do next? Start the IV solution as prescribed. Consult the prescriber about the prescription. Hang 0.9% normal saline at 125 mL/h. Hang the IV solution prescribed at 62 mL/h.

Consult the prescriber about the prescription. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the bloodstream. Its use is usually reserved for severe hyponatremia (sodium <115 mEq/L). If this client were experiencing a fluid volume deficit, this IV solution could worsen the condition. The nurse should consult with the HCP about this prescription. The nurse does not have prescribing rights and cannot change the prescription. The IV rate of 62 mL/h may still be dangerous for this client, and the rate was prescribed at 125 mL/h.

The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do? Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle. Place the eye drops in the hospital medication drawer and administer as labeled on the bottle. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital. Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.

Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital. In order to prevent medication errors, clients may not use medications they bring from home; the HCP will prescribe the eye drops as required. It is not safe to place the eye drops in the client's medication box or to permit the client to use them at the bedside. The nurse should ask the wife to take the eye drops home.

At 0900, the nurse started an infusion of one liter of D5NS infusing at a keep-vein-open rate. At 0945, the client reports a pounding headache, is dyspneic, is experiencing chills, and has a heart rate of 116 bpm. The nurse notes that the IV bag has 400 mL remaining. The nurse should take which action first? Assess the client's blood pressure. Remove the IV catheter. Call the health care provider (HCP). Slow the IV infusion.

Slow the IV infusion. The nurse notes that 600 mL of D5NS has infused over 45 minutes. The client is showing signs of circulatory overload, and the first action the nurse should take is to slow the IV infusion as the source of the problem. The nurse can then elevate the head of the bed to improve the client's ability to breathe and notify the HCP of the change in condition. The nurse should not remove the IV catheter unless there is infiltration as the open line may be needed for administration of medications.

A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. Request that cephalexin be sent promptly. Administer the cefazolin. Return the cefazolin to the pharmacy. Contact the pharmacy and speak to a pharmacist. Verify the medication order as written by the by the health care provider. (HCP).

Verify the medication order as written by the by the health care provider. (HCP). Contact the pharmacy and speak to a pharmacist. Request that cephalexin be sent promptly. Return the cefazolin to the pharmacy. One of the "five rights" of drug administration is "right medication." Cefazolin was not the medication prescribed. The pharmacist is the professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse.

A client takes hydrochlorothiazide (HCTZ) for treatment of hypertension. The nurse should instruct the client to report which effects? Select all that apply. lethargy confusion abdominal cramping muscle weakness diarrhea muscle twitching

abdominal cramping lethargy muscle weakness HCTZ is a thiazide diuretic used in the management of mild to moderate hypertension and in the treatment of edema associated with heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium, and bicarbonate. Side effects include drowsiness, lethargy, and muscle weakness but not muscle twitching. Although there may be abdominal cramping, there is no diarrhea. The client does not become confused as a result of taking this drug.

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? anemia hypertension dysmenorrhea acne vulgaris

hypertension Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Iron-deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne.

After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which as an adverse effect? headache weight gain nausea ovarian cancer

ovarian cancer The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancers are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis.

A nurse has been asked to insert peripheral I.V. lines in several clients on the nursing unit. Which site would the nurse need to avoid in order to maintain client safety? the tattooed arm of a motorcycle rider diagnosed with kidney failure the arm of a client where an arteriovenous shunt has been inserted the unaffected arm of a woman who has had a radical mastectomy the sunburned arm of a teenager admitted for hydration therapy

the arm of a client where an arteriovenous shunt has been inserted The nurse should avoid the arm with an arteriovenous shunt so the shunt is not jeopardized if the I.V. infiltrates, if the area becomes infected or inflamed, or if a thrombosis develops. The other options are incorrect because they could be used without risk to the client. It would be unsafe to use the affected side of a client who has had a mastectomy, but the unaffected side would be appropriate. The nurse should avoid broken or inflamed skin, but a sunburn without blisters could be considered.

A nurse who is a practicing Jehovah's Witness is asked by a client whether or not to consent to having a blood transfusion. Which would be the appropriate response by the nurse in this situation? "You should not have a blood transfusion. I can share with you why I am against them." "It is not part of my job to discuss blood transfusions. I will call your doctor." "I should not talk about transfusions. But I will ask another nurse to speak to you." "It is your opinion that is important. How do you feel about the transfusion?"

"It is your opinion that is important. How do you feel about the transfusion?" The correct answer allows recognition of the nurse's own values and opinions but also leaves the focus of the therapeutic relationship on the client. This response also recognizes that the feelings and values of the client are important. The nurse recognizes that the client needs to discuss the transfusion and tries to explore it further. The other options do not allow for the client's needs to be met.

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor? "The corticosteroids may help my baby's lungs mature." "I will be taking corticosteroids until my baby's due date so that he will have the best chance of doing well." "The goal of the corticosteroids is to stop contractions and help me get to my due date." "If I take corticosteroids, my baby will not have to spend any time in the neonatal intensive care unit when he is born."

"The corticosteroids may help my baby's lungs mature." Corticosteroids given IM have been shown to increase fetal lung maturity by increasing surfactant and reduce the risk of respiratory distress syndrome in premature infants. It is not a guarantee that a premature newborn would not have problems at birth that would require time in the neonatal intensive care unit. The administration of the corticosteroids is normally completed within 24 to 48 hours.

The client was recently diagnosed with a hiatal hernia. The healthcare provider orders an antacid that has reduced adverse effects. What should the nurse include in the client's teaching about the side effects of antacids? "The major side effect of an antacid is diarrhea." "A side effect of an antacid is fast breathing." "A side effect of an antacid is a decreased urge to urinate." "The major side effect of an antacid is profuse sweating."

"The major side effect of an antacid is diarrhea." Major side effects of antacids include diarrhea, constipation, dry mouth, gas, nausea, and stomach pain. These should be explained to the client. Side effects do not include profuse sweating, decreased urge to urinate, or fast breathing. Some antacids, depending on the type, can cause dry mouth, increased urge to urinate, and slow breathing.

Which statement by a client who has been taking buspirone as prescribed for 2 days indicates the need for further teaching? "This medication will help my tight, aching muscles." "I can take the medication with food." "The drug does not cause physical dependence." "I may not feel better for 7 to 10 days."

"This medication will help my tight, aching muscles." Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

A client begins taking haloperidol. After a few days, the client experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as dystonia. akathisia. parkinsonism. psychotic symptoms.

dystonia. These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. Mistaking the symptoms for psychotic symptoms can lead to misdiagnosis. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)? epoetin alfa 6500 U SQ daily. levothyroxine sodium 0.125 mcg po daily. diazepam 5 mg po on-call to the OR. acetaminophen 550 mg po every 4 hours for fever greater than 102 degrees F.

epoetin alfa 6500 U SQ daily. The order written as "Epoetin alfa 6500 U SQ daily" is incorrect according to the Joint Commission's "do not use" list. "U" should not be used because it may be mistaken as zero (0), 4 (four), or cc. The healthcare professional should write "unit" instead. The other medication orders are written correctly. The order for diazepam does not include a trailing zero in the dosage. The order for levothyroxine sodium includes a leading zero prior to the dose. The acetaminophen order is correct in the use of the word "every" instead of Q.D., QD, q.d., or qd.

A woman is taking oral contraceptives. The nurse teaches the client to report which complication? mild headache weight gain of 3 lb (1.4 kg) breakthrough bleeding severe calf pain

severe calf pain Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.

The nurse is caring for a client who has a new prescription for amitriptyline for depression and is preparing to be discharged. What assessment is the nurse's priority? constipation and dry mouth suicidal ideation extrapyramidal effects orthostatic hypotension

suicidal ideation All the listed side effects can occur with tricyclic antidepressants (TCAs). However, due to the high risk for fatal overdose when ingested for suicide attempt, the nurse's priority is to assess for suicidal ideation. Other precautions include limiting the supply of TCAs dispensed to decrease the risk for fatal overdose. If active suicidal ideation is present, the nurse should notify the prescribing healthcare provider prior to discharging the client. TCAs do cause anticholinergic effects, which include dry mouth, constipation, nausea, vomiting, and urinary retention. There is also a risk for extrapyramidal side effects and orthostatic hypotension, so the nurse should teach the client about these. None of these, however, are priority over assessing for suicide risk at the time of discharge.

A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? "Take the antibiotics 2 hours after the oral contraceptive." "You should stop taking the oral contraceptives while taking the antibiotic." "Use a barrier method of birth control for the rest of your cycle." "Call your health care provider for increased hunger or fluid retention."

"Use a barrier method of birth control for the rest of your cycle." Antibiotics may decrease the effectiveness of oral contraceptives. The client should be instructed to continue the contraceptives and use a barrier method as a backup method of birth control until the next menstrual cycle. The client should not stop taking her oral contraceptives, and there is no indication for or benefit to taking the antibiotic 2 hours after the contraceptive. There is no incidence of the adverse effects of increased hunger and fluid retention with the interaction of antibiotic therapy and oral contraceptives.

The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order? deferoxamine montelukast ramipril flurazepam

deferoxamine Deferoxamine is used for the treatment of iron overload by ridding the body of the extra iron. Montelukast is a bronchodilator used for chronic asthma. Ramipril is a antihypertensive used to treat hypertension. Flurazepam is a sedative/hypnotic that is used for insomnia.

A nurse is preparing to give an average-size 9-year-old child a preoperative I.M. injection. Which size needle should the nurse use? 20G, 1″ 22G, 1″ 20G, 1½″ 22G, 1½″

22G, 1″ The nurse should evaluate the muscle mass and amount of subcutaneous fat and then select the correct needle size. Without more information, the nurse would select the 22G, 1″ needle, appropriate for an average-size school-age child. The 20G, 1″ needle would be unnecessarily large. The 22G, 1½″ needle would be too long. The 20G, 1½″ needle would be too long and unnecessarily large.

After surgery, the client is receiving epidural pain management. The client wants to get out of bed and walk to the bathroom. The nurse should base the decision to ambulate on which information? The epidural medication affects the sympathetic and motor function. A low concentration of analgesia is used with the catheter. The analgesia from the epidural catheter bathes the spinal fluid. The analgesia is periodically administered through the epidural catheter.

A low concentration of analgesia is used with the catheter. The client who has epidural pain management postoperatively can ambulate because a low concentration of local analgesia causes sensory blockage only. The catheter is placed so that constant pain management plus patient-controlled administration of an analgesic dose can block sensory innervation. Motor function should not be affected since the catheter is placed above the dura lining the spinal fluid. If the catheter would move through the dura sac, spinal analgesia would occur, affecting motor function as well as sympathetic nervous system function.

The nurse is reviewing the physician's order written for a postmenopausal client: "calcitonin salmon nasal spray 200 IU, one spray every day." What is the appropriate action to be taken by the nurse regarding this order? Ask the physician why this medication was ordered for a postmenopausal client. Inform the physician that the medication is not a nasally applied medication. Clarify with the physician that the spray should be given in only one nostril per day. Remind the physician that this medication can be purchased over-the-counter.

Clarify with the physician that the spray should be given in only one nostril per day. Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print "administer in both nostrils" when a nasal spray is ordered. Nurses must be familiar with the directions for each medication they give before administering medications. The other options are incorrect because calcitonin salmon nasal spray is prescribed to postmenopausal clients for the treatment of osteoporosis and requires a physician's order.

The client is admitted for a myocardial infarction and has a heparin drip infusing. Which signs and symptoms would prompt the nurse to stop the infusion and notify the prescribing health care provider? Pain and stiffness to left shoulder Report of upset stomach and nausea New onset bleeding from client's rectum Unrelieved chest pain

New onset bleeding from client's rectum Heparin is a medication used to help prevent blood clots, and can be used in the treatment of myocardial infarction to prevent more blood clots. When a client is receiving a heparin infusion, the nurse must be alert to signs and symptoms of bleeding, as the heparin may need to be discontinued. New onset of rectal bleeding would indicate that the nurse should stop the heparin infusion and notify the provider immediately. Unrelieved chest pain, upset stomach and nausea, and left shoulder pain/stiffness are common symptoms during a myocardial infarction, and may necessitate the nurse notify the attending health care provider, but would not be indications for stopping the heparin drip.

A client is receiving lithium carbonate for a bipolar disorder. The nurse is aware that early signs of lithium toxicity include: diarrhea tinnitus akathisia torticollis

diarrhea Gastrointestinal symptoms are the initial symptoms of lithium toxicity. Torticollis is a side effect of cholinergic medications. Tinnitus is a common side effect with aspirin. Akathisia is a common side effect of antipsychotic medications.

After surgery, a client was treated for postoperative nausea and vomiting and now is experiencing hypotension and tachycardia. The nurse should review the medication record to determine if the client has received which medication? prochlorperazine promethazine ondansetron hydrochloride droperidol

droperidol Hypotension and tachycardia are common adverse effects of droperidol and should be monitored closely by the nurse. Hypotension and tachycardia are not common adverse effects of ondansetron hydrochloride, prochlorperazine, or promethazine.

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply. Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse. Ask the unit clerk to listen on the speakerphone with the nurse and write down the prescription. Repeat the prescription to the HCP. Ask the HCP to confirm that the prescription is correct as understood by the nurse. Ask the HCP to come to the hospital and write the prescription on the medical record.

Repeat the prescription to the HCP. Ask the HCP to confirm that the prescription is correct as understood by the nurse. To ensure client safety in obtaining telephone prescriptions, the prescription must be received by a registered nurse (RN) . The nurse should write the prescription, read the prescription back to the HCP, and receive confirmation from the HCP that the prescription is correct. It is not necessary to ask the unit clerk to listen to the prescription, to require the HCP to come to the hospital to write the prescription on the medical record, or to have the nursing supervisor cosign the telephone prescription.

A health care provider (HCP) has prescribed amoxicillin 100 PO two times a day. What should the nurse instruct the client to do? Select all that apply. Take time to empty the bladder completely. Drink 300 to 500 mL of fluids daily. Take the last dose of the antibiotic for the day at bedtime. Take the antibiotic with or without food. Void frequently, at least every 2 to 3 hours.

Void frequently, at least every 2 to 3 hours. Take time to empty the bladder completely. Take the last dose of the antibiotic for the day at bedtime. Take the antibiotic with or without food. Amoxicillin may be given with or without food, but the nurse should instruct the client to obtain an adequate fluid intake (2,500 to 3,000 mL) to promote urinary output and to flush out bacteria from the urinary tract. The nurse should also encourage the client to void frequently (every 2 to 3 hours) and empty the bladder completely. Taking the antibiotic at bedtime, after emptying the bladder, helps to ensure an adequate concentration of the drug during the overnight period.

The nurse should warn a client who is taking a benzodiazepine about using which medication in combination with his current medication? vitamins aspirin acetaminophen antacids

antacids Combining a benzodiazepine with an antacid impairs the absorption rate of the benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because no major drug interactions occur.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse? Ask the client to state name and birthdate. Recall the client's facial features to verify the client's identity. Ask two staff members to state the name of the client in the room. Give client paper and pencil with which to write name and birthdate.

Ask the client to state name and birthdate. The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write the name and birthdate as the client has ataxia. Ataxia involves muscle movement, typically in the arms (making fine motor movements, such as writing, difficult) and legs, though speech may be slurred. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity.

A physician orders an I.V. bolus injection of diltiazem hydrochloride for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus? Warm the I.V. medication to room temperature. Insert a second I.V. line into the opposite arm. Place a tourniquet on the arm in which the injection will be administered. Gently aspirate the I.V. catheter to check for a blood return.

Gently aspirate the I.V. catheter to check for a blood return. Before administering an I.V. bolus, the nurse should gently aspirate the I.V. catheter for a small amount of blood to ensure correct placement of the I.V. catheter. Then the nurse may inject the medication over the recommended time interval. The nurse doesn't need to insert another I.V. line unless the ordered medication is incompatible with the medication in the I.V. solution. Warming the medication could alter the drug's action. Placing a tourniquet on the arm would close off the venous system and prevent drug injection.

The nurse is admitting a client directly from a healthcare clinic. The healthcare provider's orders are illegible. What should the nurse do next? Select all that apply. Call the healthcare provider to clarify orders. Start implementing orders. Have the nursing supervisor help you interpret the orders. Call the pharmacist to clarify orders. Hold all orders.

Hold all orders. Call the healthcare provider to clarify orders. If the nurse cannot correctly interpret the components of a medication order, the nurse should hold the orders and call the healthcare provider for clarification. The only person that can interpret the components of the orders are the person who wrote the orders.

Which is the correct technique when the nurse is instilling eye drops for an adult who is alert? Select all that apply. Have the client tilt the head back and look up. Instruct the client to apply pressure to the eyes after instillation of the eyedrops. Blot excess drops from the client's face. Have the client look down, and instill the medication onto the client's cornea. Hold the dropper over the eye, and instill the drops into the lower lid.

Hold the dropper over the eye, and instill the drops into the lower lid. Have the client tilt the head back and look up. Blot excess drops from the client's face. Correct technique for instilling eyedrops includes having the client tilt the head back and look up to protect the cornea; holding the dropper over the eye and pulling the lower eyelid down to release the drops in the conjunctival sac.The client should not apply pressure on the eyes and can gently apply pressure over the inner canthus to prevent systemic absorption of the drug, but is not told to apply pressure to the eyes. The drops should not be instilled on the cornea.After instilling the medication the nurse can blot any excess medication from the clients face.

What information should the nurse provide to the client who is receiving warfarin? International Normalized Ratio (INR) is used to assess effectiveness. Warfarin sodium will facilitate clotting of the blood. Partial thromboplastin time values determine the dosage of warfarin sodium. Protamine sulfate is used to reverse the effects of warfarin sodium.

International Normalized Ratio (INR) is used to assess effectiveness. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.

The nurse is reviewing laboratory values on a client with heart failure and atrial fibrillation. The client has a potassium level of 2.8 mEq/L (2.8 mmol/L). The client is scheduled to receive their 0900 dose of digoxin. What is the nurse's best action? Draw a stat potassium level and compare the earlier result with the current result. Review the dietary needs of the client and consult the dietitian. Administer the dose of digoxin and offer the client a banana with breakfast. Withhold the dose of digoxin and notify the healthcare provider. Give half of the digoxin and offer potassium-rich foods all day.

Withhold the dose of digoxin and notify the healthcare provider. Administering the dose of digoxin should not be done. The effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity may occur. Drawing a stat potassium level and comparing the earlier result with the current result does not address the low potassium level. The level could be lower, putting the client at risk for a cardiac event. Offering the client a banana with breakfast will not raise the potassium level because the banana does not contain enough potassium. Withholding the dose of digoxin should be done to prevent digoxin toxicity. The nurse should notify the healthcare provider to let them know about the low potassium level. The healthcare provider can order a potassium supplement orally or intravenously and another potassium level laboratory value to be drawn after treatment to evaluate if the level is within normal limits after treatment. Giving half of the digoxin may cause digoxin toxicity because of the low potassium level. Offering potassium-rich foods all day will not do much to increase the potassium level. Reviewing the dietary needs of the client and consulting the dietitian is not warranted at this time.

The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which client would not have delayed fluid restrictions? The client who had: an inguinal herniorrhaphy with spinal and intravenous conscious sedation. a repair of carpal tunnel syndrome under local anesthesia. undergone a bronchoscopy under local anesthesia. a transurethral resection of a bladder tumor under general anesthesia.

a repair of carpal tunnel syndrome under local anesthesia. The client who has not had the gag reflex anesthetized is the client who had a repair of the carpal tunnel syndrome under local anesthesia because the area being anesthetized was the tissue in the wrist. The client who had a bronchoscopy received a local anesthetic on the vocal cords, and the nurse should check the gag reflex or ability to swallow before administering fluids. Clients who had general anesthesia or intravenous conscious sedation received medication for central nervous system sedation, and the nurse should assess the level of consciousness and ability to swallow before administering fluids.

A nurse is administering sublingual nitroglycerin to a client. Immediately after administering nitroglycerin, the nurse should expect to administer alprazolam. insulin. acetaminophen. prednisone.

acetaminophen. In the early stages of therapy, nitroglycerin commonly causes headache and dizziness. Acetaminophen usually helps decrease nitroglycerin-induced headaches. Although the client may be anxious, lorazepam usually isn't given after nitroglycerin. There is no indication that the client would need insulin or prednisone.

Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration? altered drug absorption altered onset of action altered duration altered drug dose

altered drug dose Although not harmful to the client when injected, small air bubbles can actually change the dose of medication administered; therefore, the nurse should remove the air bubbles. Small air bubbles won't affect the drug's onset of action, duration, or absorption. Air bubbles may be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

A client who is taking lithium carbonate is going home on a 3-day pass. What is the best health teaching the nurse should provide for this client? Avoid participation in controversial discussions with friends and family about the medication during the 3-day pass. Have a low-sodium, high-protein snack with milk before going to bed. Adjust the lithium dosage if mood changes are noted throughout the day. Continue to maintain normal sodium intake while at home.

Continue to maintain normal sodium intake while at home. Lithium decreases sodium reabsorption by the renal tubules. If sodium intake is decreased, sodium depletion can occur. In addition, lithium retention is increased when sodium intake is decreased. Reduced sodium intake can lead to lithium toxicity. Nursing is not allowed to tell a client to adjust dosages of any drugs. A low-protein snack is not reflective or needed with this drug. Avoiding participation is not a therapeutic discussion.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first? Continue to give the medication because the client has been taking it for 3 days. File an incident report because several other staff members have given the medication to the client. Find out whether there are extenuating reasons for giving the drug to this client. Hold the medication and report the information to the physician to ensure client safety.

Hold the medication and report the information to the physician to ensure client safety. The nurse should report the information to the physician because the client's safety may be endangered. The nurse shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Give the medications and check vital signs later. Give the scheduled medications. Call the supervisor and ask what to do.

Hold the medications. Call the healthcare provider and provide a report of the events and vital signs. Considering the ordered medications verapamil and atenolol, the pulse rate, and blood pressure, the medications should be held and the healthcare provider should be notified about the events and vital signs of the client. The healthcare provider will decide whether to give the medication or hold at this time. Verapamil and atenolol can cause slow heartbeat, so if the heartbeat is already slow, the medications should be held.

The nurse observes a new parent give an oral medication to a 4-month-old infant. The parent instills the medication directly in the back of the infant's throat. Which choice is the nurse's best action? Have the parent lay the infant flat, restraining the arms, while giving the medication. Praise the parent's technique of giving the medication. Demonstrate to the parent ways to prop the infant in a sitting position for medication administration. Instruct the parent to instill a small amount of the medication inside the baby's cheek.

Instruct the parent to instill a small amount of the medication inside the baby's cheek. The parent's technique of instilling the medication in the back of the throat is not correct and could cause the infant to choke. The nurse should instruct the parent to instill a small amount at a time inside the infant's cheek. The parent should hold an infant in the bottle-feeding position when administering an oral medication by placing the child's inner arm behind the back, supporting the head in the crook of the elbow, and holding the child's free hand with the hand of the supporting arm. Propping a 4-month-old infant is not appropriate. The infant cannot sit unsupported even in a seated position. Administering medication to an infant lying flat could cause choking and aspiration.

The client who is just starting to wake up from a moderate sedation procedure repeatedly asks the nurse, "Where am I? What happened to me?" What action does the nurse take in response to the client's condition? No action is required based on the client's condition. Assess the client for signs of an acute head injury. Assess the client for evidence of acute stroke. Request a reversal agent for the medications administered.

No action is required based on the client's condition. Confusion, repeated questions, and amnesia of the procedure and events are normal behaviors in a client who is just beginning to wake up from moderate sedation due to the amnesic, sedating, and hypnotic effects of the medications used. While repetitive questioning and confusion could be signs of a head injury or stroke, in this scenario they are an expected side effect of the medications given and should resolve as the client metabolizes the medications. Confusion during the initial recovery phase is not a severe adverse reaction to the procedure or medications, but an expected temporary state of altered mental status.

The nurse reviews a client's medication administration record and notes the scheduled medications (see chart). When planning to administer the medications, the nurse must administer which medication within 30 minutes of its scheduled administration time? ampicillin metoprolol pneumococcal vaccine lisinopril

ampicillin Time-critical medications are those medications that can cause client harm or subtherapeutic blood levels and should be administered within 30 minutes of the scheduled time. These include antibiotics, anticoagulants, immunosuppressants, insulin, and antiseizure medications. Non-time-critical medications, such as lisinopril, metoprolol, and the pneumococcal vaccine should generally be administered within 1 to 2 hours of the scheduled time. However, agency policy dictates the window of time to administer non-time-critical medications and may vary by institution.

The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then: report them to the supervisor. ask them to attend in-service training for administration of IV medications. document it on their evaluations. report the incidents to the hospital attorney.

ask them to attend in-service training for administration of IV medications. Identification of causes of medication errors requires in-service education to inform the staff of strategies to decrease these errors. Errors are frequently the result of systemic problems that can be identified and rectified through problem-solving techniques and changes in procedures.Documenting or reporting the situation would not directly assist the nurses in eliminating errors.Reporting the incidents to the hospital attorney is unnecessary.