N310: EXAM 2 / ATI
a nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. when the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. what is an appropriate response?
" water helps clear the tube so it doesn't get clogged"
a nurse is caring for a client who states that his provider told him he is at risk for anaphylaxis following administration of amoxicillin (Amoxil) and that he does not understand what this means. what is an appropriate response?
"anaphylaxis is a severe hypersensitivity or allergic rxn that is life-threatening"
a nurse manager is reviewing a care of a client who has had a seizure w/ nurses on the unit. what statement by a nurse requires further instruction?
"i will go to the nurses' station for assistance"
a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. what following statements by a nurse indicates understanding of proper procedure?
"i will listen for background noises" you should listen for distinguishing background noises such as: church bells, train whistles, other voices
a nurse is teaching the daugther of an older adult pt how to instill eye drops in the pt's right eye. what indicates that the daughter understood the directions?
"i will pull down her lower eyelid and drop the medication inside"
a nurse is caring for an unconcscious patient. what statement by the nurse indicates an understanding of providing good oral hygiene?
"i'll swab the patient's mouth with diluted hydrogen peroxide"
a nurse is caring for a pt who's been prescribed a fluticasone propinate (flovent HFA) inhaler w/ a spacer. the pt asks the nurse why a spacer is needed w/ the inhaler. what response by the nurse is correct?
"more medication is delivered to the lungs when you use a spacer."
a nurse educator is conducting a parenting class for new parents. what statement made by a participant indicates a need for further clarification and instruction?
"once my baby can sit up, he should be safe in the bathtub"
a nurse is caring for an adult pt who is NPO. pt is refusing oral care. what's an appropriate response?
"oral care is still important even though you are not eating."
a nurse on a med-surg unit is informed that a mass casualty event occurred in the community & that it's necessary to discharge clients to make beds available for injury victims. what clients can be safely discharged?
- client who's scheduled for a transurethral resection of the prostate (TURP) [not an emergent surgery] - client who's 24 hr postoperative following a mastectomy (client is stable)
a nurse in a provider's office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. the client relates a hx of 3 vaginal births, but no serious accidents/illnesses. what interventions are appropriate for helping to control/eliminate the client's incontinence?
- decrease or avoid caffeine - avoid the intake of alcohol * because stress incontinence results from weak plevic muscles & other structures, limiting fluids will not resolve the problem * caffeine & alcohol are bladder irritants & can worsen stress incontinence
a nurse educator on a medical unit is reviewing factors that increase the risk of UTIs w/ a group of AP. what should be included in the review?
- having sexual intercourse on a frequent basis - undergoing frequent catheterization
a nurse is preparing to administer trazodone (Oleptro) 50 mg PO at bedtime. available is trazodone 100 mg tablets. how many tablets should the nurse administer per dose?
0.5
a nurse is preparing to administer levothyroxine (Synthroid) 0.25 mg IV bolus stat. available is levothyroxine injection 500 mcg/mL. how many mL should the nurse administer? round to nearest tenth.
0.5 mL
a nurse is preparing to administer lorazepam (Ativan) 2 mg IV bolus 20 min prior to surgery. available is lorazepam injection 4 mg/mL. how many mL should the nurse administer? round to nearest tenth.
0.5 mL
a nurse is preparing to administer famotidine (Pepcid) 20 mg PO every 12 hr. available is famotidine 40 mg tablets. how many tables should the nurse administer per dose?
0.5 tablets
a nurse is preparing to administer methylprednisolone (Medrol) 4 mg PO daily. available is methylprednisolone 8 mg tablets. how many tablets should the nurse administer daily?
0.5 tablets
a nurse is preparing to administer diazepam (Valium) 3 mg IV bolus every 3 hr PRN for anxiety. available is diazepam injection 5 mg/mL. how many mL should the nurse administer per dose? round to nearest tenth.
0.6 mL
a nurse is transcribing medication prescriptions for a group of clients. what is an example of the appropriate way for the nurse to record medications that require the use of a decimal point?
0.6 mL
a nurse is preparing to administer methylprednisoline acetate (Depo-Medrol) 15 mg IM every other week. available is methylprednisolone acetate injection 20 mg/mL.
0.8 mL
proper needle length when giving an IM injection in the ventrogluteal area to an average-sized adult is what?
1 1/2 inches
a pt is to receiving 30 mg of ketorolac (toradol) IM every 6 hr for 48 hr. the med is available in a 60 mg/2 mL vial. how many mL should the nurse administer for each dose?
1 mL
a nurse is caring for a client in a LTC facility who is receiving enteral feedings via an NG tube. what are appropriate nursing actions prior to administering the tube feeding?
1. auscultate bowel sounds 2. assist the client to an upright position 3. test the pH of gastric aspirate * if you can't hear bowel sounds, the pt's GI tract might not be able to absorb nutrients. withhold feedings & notify provider. * most reliable method is to do an x-ray to verify placement of NG tube but it's impractical prior to every feeding. so test the pH of gastric aspirate.
a nurse working in a medical surgical unit is preparing to administer medications to a client. the nurse plans to use 2 forms of ID to verify that she the right client. what actions should the nurse take to ID the client?
1. compare the name on the client's wristband with the name on the MAR 2. ask the client to state his DOB 3. ask the client to state his name 4. use the bar code scan to ID the client
a nurse is caring for a client who was just admitted to the unit after falling at a nursing home. this client is oriented to person, place, & time & can follow directions. what actions by the nurse are appropriate to decrease the risk of a fall?
1. ensure that the client's call light is within reach 2. provide the client w/ nonskid footwear 3. complete a fall-risk assessment
a nurse is preparing to assist a pt w/ a hot tub bath. what steps should the nurse take?
1. gather all necessary supplies 2. place a rubber mat on the tub floor 3. assist the pt into the bathroom 4. instruct the pt on using safety bars when getting in & out of the tub 5. instruct the pt to remain in the tub for no longer than 20 min
a nures is preparing to initate a bladder training program for a client who has a voiding disorder. what actions should the nurse take?
1. have the client record voiding times 2. gradually increases the voiding intervals 3. remind client to hold urine until next schedule voiding time
a home health nurse is discussing the dangers of food poisoning w/ a client. what info should the nurse include in her counseling?
1. immunocompromised individuals are at risk for complications from food poisoning 2. clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products 3. handling raw & fresh food separately to avoid across contamination may prevent food poisoning
a nurse is instructing a client who has diabetes mellitus about foot care. what guidelines should the nurse include?
1. inspect the feet daily 2. use moisturizing lotions on the feet (but not between the toes) 3. check shoes for any foreign objects
a nurse is providing discharge instructions to a client who has a prescription for the use of O2 in his home. what should the nurse teach the client about using oxygen safely in his home?
1. nail polish should no be used near a client who's receiving O2 2. a "no smoking" sign should be placed on the front door 3. a fire extinguisher should be readily available in the home
a nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. what info should the nurse include?
1. older adults are more prone to dehydration than younger adults are 2. older adults need the same amt of most vitamins & minerals as younger adults do 3. many older men & women need calcium supplementation
a nurse educator is discussing the facility protocol in the event of a tornado w/ the staff. what should the nurse include in the instructions?
1. place blankets over clients who are confined to beds 2. move beds away from the windows 3. draw shades & close drapes
a nurse is planning atraumatic care for a preschooler who has a prescription for an intramuscular medication. a parent is with the child. what actions should the nurse include in the plan of care?
1. provide an explanation of the hospital alarm system 2. suggest the parent bring the child's favorite toy to the hospital 3. use a doll to demonstrate how the nurse will administer the IM medication
a nurse is preparing to administer potassium chloride 40 mEq PO daily. available is potassium chloride 20 mEq effervescent tablets. in addition to checking the correct dosage before administering the medication, the nurse should check what?
1. the amount of liquid in which to dissolve the tablets 2. the type of liquid in which to dissolve the tablets 3. the acceptable dose range of the medication
a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. what are steps for the nurse to take?
1. warm the enema solution prior to instillation 2. position the client on the left side w/ the right leg flexed forward 3. lubricate the rectal tube or nozzle * adults = insert tube 3-4 in * children = insert tube about 2 in * recommended height above client = 18 in
a nurse is planning on obtaining a urinary specimen from a pt's closed urinary system. identify the sequence of steps the nurse should take.
1. wipe the port w/ an alcohol swab 2. insert a 10 mL syringe & needle into the port 3. withdraw a 5 mL of urine 4. transport the urine to a sterile specimen container 5. transport the specimen to the laboratory
a nurse is preparing to administer ceftriaxone (Rocephin) 400 mg IM every 12 hr. available is ceftriaxone injection 350 mg/mL. how many mL should the nurse administer per dose? round to nearest tenth.
1.1
a nurse is preparing to administer diazepam (Valium) 7 mg IV bolus every 4 hr PRN for muscle spasm. available is diazepam injection 5 mg/mL. how many mL should the nurse administer per dose? round to nearest tenth.
1.4 mL
a nurse is preparing to administer furosemide (Lasix) 60 mg PO daily. available is furosemide 40 mg tablets. how many tablets should the nurse administer daily?
1.5 tablets
a nurse is preparing to administer imipramine hydrochloride (Tofranil) 75 mg PO daily. available is imipramine hydrochloride 50 mg tablets. how many tablets should the nurse administer?
1.5 tablets
a nurse is preparing to administer acetaminophen (Tylenol) 250 mg PO every 4 hr. available is acetaminophen oral suspension 120 mg/5 mL. how many mL should the nurse administer per dose? round to nearest whole number.
10 mL
a nurse is preparing to administer albuterol (Proventil) 4 mg PO every 6 hr. available is albuterol syrup 2 mg/5 mL. how many mL should the nurse administer per dose? round to nearest whole number.
10 mL
a nurse is preparing to administer ethosuximide (Zarontin) 500 mg PO every 12 hr. available is ethosuximide syrup 250 mg/tsp. how many ML should the nurse administer? round to nearest whole number.
10 mL * convert tsp to mL
a nurse is preparing to administer potassium chloride (K-lor) 15 mEq PO every 12 hr. available is potassium chloride liquid 20 mEq/15 mL. how many mL should the nurse administer per dose? round to nearest whole number.
11 mL
a nurse is preparing to administer lamivudine (Epivir) 150 mg PO every 12 hr. available is lamivudine oral solution 10 mg/mL. how many mL should the nurse administer per dose? a nurse is preparing to administer
15 mL
a nurse is preparing to administer lithium carbonate (Eskalith) 600 mg PO. available is lithium carbonate 300 mg capsules. how many capsules should the nurse administer? round to nearest whole number.
2 capsules
a nurse is preparing to administer digoxin (Lanoxin) 0.2 mg IV bolus daily. available is digoxin injection 0.1 mg/mL. how many mL should the nurse administer per dose?
2 mL
a nurse is preparing to administer penicillin G benzathine (Bicillin L-A) 1,200,000 units IM every week for 3 weeks. available is penicillin G benzathine injection 2,400,000 units/4 mL. how many mL should the nurse administer per dose?
2 mL
a nurse is preparing to administer doxycycline (Vibramycin) 100 mg PO every 12 hr. available is doxycycline 50 mg tablets. how many tablets should the nurse administer per dose? round to nearest whole number.
2 tablets
a nurse is preparing to administer methadone (Dolophine) 10 mg PO every 3 hr. available is methadone 5 mg tablets. how many tablets should the nurse administer per dose? round to nearest whole number.
2 tablets
a nurse is preparing to administer quinapril (Accupril) 40 mg PO daily. available is quinapril 20 mg tablets. how many tablets should the nurse administer daily? round to nearest whole number.
2 tablets
a nurse is preparing to administer triazolam (Halcion) 0.25 mg PO every 12 hr PRN for agitation. available is triazolam 0.125 mg tablets. how many tablets should the nurse administer per dose? round to nearest whole number.
2 tablets
a nurse is preparing to administer zolpidem (Ambien) 10 mg PO at bedtime. available is zolpidem 5 mg tablets. how many tablets should the nurse administer per dose?
2 tablets
a nurse is preparing to administer amoxicillin (Amoxil) 500 mg PO every 8 hr. available is amoxicillin oral suspension 250 mg/5 mL. how many tsp should the nurse administer per dose? round to nearest whole number.
2 tsp * convert 5 mL to tsp
a pt is receiving 12.5 mg of prednisone (Deltasone) by mouth daily. med available in 5 mg tablets. how many tablets should the nurse administer for each dose?
2.5 tablets
a pt drinks 8 oz of water. what is the equivalent in mL?
240 mL
a nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. calculate her BMI & determine whether this client is obese.
31 * BMI = wt (kg) / ht (m2) BMI = 80 / 1.622 = 80 / 2.56 = 31.25
a pt is to receive 1 g of ceftriaxone (Rocephin) in 100 mL over 30 min. the tubing drip rate is 10 gtt/mL. the nurse should adjust the flow rate to what infusion rate?
33 gtt/min
a nurse is preparing to administer furosemide (Lasix) 40 mg IV bolus state. available is furosemide injection 10 mg/mL. how many mL should the nurse administer?
4 mL
a nurse is preparing to administer hydromorphone (Dilaudid) 4 mg PO every 6 hr PRN for pain. available is hydromorphone oral liquid 5 mg/5 mL. how many mL should the nurse administer per dose? round to nearest whole number.
4 mL
a nurse is preparing to administer rifampin (ifdain) 0.6 g PO daily. available is rifampin 150 mg tablets. how many tablets should the nurse administer? round to nearest whole number.
4 tablets * convert mg into g
a pt has finished a 16-oz container of orange juice. the I&O sheet documents fluid in milliliters. what should the nurse document as intake?
480 mL
a nurse is preparing to administer a medication subcutaneously. what should the nurse use?
5/8-inch, 25 gauge needle
a nurse is administering an enema medicated w/ sodium polystyrene sulfonate (Kayexalate) to an older adult pt who has hyperkalemia. the nurse should insert the tip of the rectal tube
7.5 cm-10 cm (3-4 in)
a nurse is preparing to administer fluoxetine (Prozac) 35 mg PO daily. available is fluoxetine solution 20 mg/5 mL. how many mL should the nurse administer daily? round to nearest whole number.
9 mL
a nurse is administering a subcutaneous injection to a pt. what data should the nurse recognize as the highest priority to prevent potential complications?
ID if pt has allergies to the medication
a nurse is reviewing a client's prescriptions. the nurse should contact the provider to clarify what prescription?
Morphine 2.5 mg IV bolus PRN for incisional pain (prescription contains name of med, dosage, route, circumstance of administration, but no frequency ... therefore needs clarification)
during report, a nurse is inform that a pt has a nasogastric tube connected to continuous suction. the nurse should recognize that this pt must have what type of tube?
Salem sump
a nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for what pt?
a 40 yr old pt with a postoperative bowel obstruction
a charge nurse is designating room assignments for clients who will be admitted to the unit. based on the nurse's knowledge of fall prevention, what clients should be assigned to the room closest to the nurses' station?
a 79 y/o client who is postoperative following a BTK amputation
a pt who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. the nurse should explain the option that will allow that is
a Kock's pouch
a nurse is caring for a pt w/ a peripherally inserted central catheters (PICC line). what is true about this type of IV route?
a PICC line is a long catheter inserted through the veins of the antecubital fossa
a nurse is caring for multiple clients during a mass casualty event. what client is the highest priority?
a client who has partial-thickness & full-thickness burns to his face, neck & chest (clients who have burns to all these are at risk for airway obstruction but are still expected to live)
what exhibits drug tolerance?
a pt requires an increased dose of a med to achieve continued therapeutic benefit
a nurse is reviewing a client's prescriptions. the nurse should contact the provider to clarify what prescription?
acetaminophen (Tylenol) 325 mg by mouth PRN for headache (prescription contains name of med, dosage, route, circumstance of administration, but no frequency)
a nurse is caring for a client who has a prescription for meperidine (Demerol) 50 mg PO every 3 hr PRN for moderate pain, & meperidine 75 mg PO every 3 hr PRN for severe pain. at 1200, the client reports back pain rated as 8 on a pain scale of 0-10. the client received 75 mg PO at 0700 & 50 mg PO at 1000. what action should the nurse take?
administer meperidine 75 mg PO now (it's been 5 hrs since the previous dose so this is the appropriate action)
a nurse on a med surg unit is caring for a client who has type 2 diabetes mellitus & has a prescription for metformin (Glucophage) 500 mg PO every 12 hr. the client is scheduled for a chest X-ray in the morning. what is an appropriate action by the nurse?
administer the medication as prescribed
what demonstrates correct use of 6 rights of med administration?
administering a patient's medication by the route the provider has prescribed
a nurse should recognize that what is correct regarding albumin level as a diagnostic marker for nutritional status?
albumin level is a poor short-term indicator of protein status
what should a nurse assess before administering meds through a nasogastric tube?
amount of residual volume left in stomach
what's an example of correct administration of the prescribed medication?
amoxicillin 1 g PO prescribed; 2 500-mg tablets given
a uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called
an idiosyncratic effect
a nurse is providing preoperative teaching for apt who has colon cancer. the surgeon informed the pt that his entire large intestine & rectum will be removed. the nurse should explain the type of ostomy he will have is
an ileostomy
a nurse is preparing to administer medication to a client who has a prescription for doxycycline (Vibramycin) 100 mg PO daily at 0800. what times are appropriate for the nurse to administer the medication?
anywhere within 30 min of the scheduled time (ex: 0745 or 0830)
a nurse who is preparing to insert a straight urinary catheter for a male pt should
apply light traction to the penis
a nurse is about to administer an IV med directly into the vein. the nurse should understand that a disadvantage of parenterally administered medications is that they ___
are irreversible
when planning morning hygiene care for a postoperative patient, what action should the nurse include?
ask the pt in what order she typically performs her morning routine
a nurse manager is reviewing a client's medical record & discovers that the client received a double dose of a prescribed medication. what action should the nurse manager take first?
assess the client for adverse effects
a nurse is preparing to administer an oil-retention enema to a pt who has constipation. the nurse explains that the pt should try to retain the instilled oil for
at least 30 mins, but preferably as long as he can.
a nurse is preparing to insert an indwelling urinary catheter for a female pt. when beginning the insertion procedure, the nurse should instruct the pt to
bear down
a nurse is preparing to perform denture care for a client who prefers to keep the dentures in a cup while he is resting. what is an appropriate action for caring for the dentures?
brush the dentures w/ a toothbrush & denture cleaner * soaking helps remove staining, but doesn't clean dentures adequately. brushing thoroughly removes debris that accumulates on & between the teeth
a nurse is preparing a presentation about basic nutrients for a group of high school athletes. she should explain that ________ is the body's priority energy source?
carbohydrates
a home health nurse is discussing the dangers of carbon monoxide poisoning w/ a client. what information should the nurse include in her counseling?
carbon monoxide binds w/ hemoglobin in the body (which ultimately reduces O2 that is supplied to the tissues in the body)
a nurse administers the first dose of a pt's prescribed antibiotic via IV piggyback. during the first 10-15 min of administration of the medication, the nurse gives priority to what assessment?
check pt for systemic allergic reaction
a nurse is caring for a pt receiving 0.9% sodium chloride (normal saline) at 75 mL/hr through a triple lumen central venous catheter. the pump is alarming that there is an occlusion. what is the first thing the nurse should do?
check the line at or above the hub for kinked tubing that is creating a resistance to flow
a client who has an indwelling catheter reports a need to urinate. what interventions should the nurse perform?
check to see whether the catheter is patent * a clogged/kinked catheter causes the bladder to fill & stimulates the need to urinate
a nurse is assisting a pt w/ personal hygiene care. what action by the nurse will reduce the risk of infection?
cleaning the least-soiled areas prior to cleaning the most-soiled areas
a nurse is replacing the ostomy appliance for a pt whose newly created colostomy is functioning. after removing the pouch, what should the nurse do first?
cleanse the stoma & the peristomal skin
a nurse inserting a nasogastric tube asks the pt to flex her head toward her chest after the tube passes through the nasopharynx. this action facilitates proper insertion of the tube by
closing off the glottis
a nurse is caring for a newly admitted client who has a documented hx of falls. what is the priority action by the nurse?
complete a fall-risk assessment
a nurse is obtaining health hx from a young adult pt who has a colostomy. the pt reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. he ports that his concerns about leakage have limited his social activities. what should the nurse recommend?
consume foods that are low in fiber content (foods low in fiber help thicken the stool: rice, noodles, white bread, cream cheese, lean meats, fish, poultry)
what action should a nurse take when removing a pt's indwelling urinary catheter?
deflate the balloon completely before removal
you're reading the physician's orders and note date and time of the prescriptions as well as the physician's signature. what prescription is complete?
digoxin (lanoxin) 1.25 mg PO daily
a provider prescribes a 24-hr urine collection for a client. what action should the nurse take?
discard the first voiding (& note time)
when teaching the parents of a toddler about feeding & eating, the nurse should include what safety measures?
do not offer the child raw vegetables (other foods such as: raw vegetables, hot dogs, grapes, nuts, popcorn, candy have all been implicated in choking deaths & should be avoided at least until the child is 3 yrs)
a pt is to receive his daily isoniazid (INH) dosage for tuberculosis. he states he's feeling nauseated with this medication and refuses to take it. the nurse knows that the correct way to indicate this refusal is to
document the reason for refusal along w/ the date and time in the pt's medical record
a nurse is assisting w/ the orientation of a newly licensed nurse. the nurse should explain that it is important to have a second nurse review the dosage of high-alert medications, such as heparin & insulin, for what reason?
dosage errors have the potential for significant harm to the client
what dietary modifications should an adolescent engaging in sports implement?
drink water before & after sports activities
what is inhalation medication delivery method is important for the nurse to assess the pt's ability to inhale deeply before administering?
dry powder inhaler (DPI)
what formula is appropriate to administer to a pt who has a dysfunctional gastrointestinal tract?
elemental
a nurse is caring for a pt who has impaired swallowing due to a cerebrovascular accident. what interventions should the nurse use to assist the pt w/ feeding?
elevate the head of the bed 45-90 degrees
a nurse is teaching a pt with a new ileostomy about incorporating preventive strategies at home. to prevent excoriation & breakdown of the peristomal skin, the nurse should instruct the pt to
empty the pouch when it's no more than half full
an older adult pt in a long-term care facility is receiving intermittent enteral feedings in his room. his affect is flat, & the nurse suspects that he's feeling isolated. what intervention is appropriate for this pt?
encourage him to go to the dining room @ meal times to talk w/ other pts
a nurse observes smoke coming from under the door of the staff lounge. what is the priority action by the nurse?
evacuate the clients
a nurse is beginning a complete bed bath for a client. after removing the client's gown & placing a bath blanket over him, what areas should the nurse wash first?
face
a nurse is admitting a client from a LTC facility to an acute-care setting. an indwelling urinary catheter was inserted just prior to her transfer. what interventions will help prevent the development of a catheter-associated infection?
frequently cleaning the client's perineal area & caring for her catheter
a nurse is talking w/ a client who reports constipation. when the nurse discusses dietary changes that can help prevent constipation, what foods should the nurse recommend?
fresh fruit & whole wheat toast
a nurse educator is presenting a module on basic first aid for newly licensed home health nurses. the nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have what?
hypotension
a nurse is caring for a client who has had diarrhea for the past 4 days. when assessing the client, the nurse should expect what findings?
hypotension, fever, poor skin tugor
when using chilled normal saline solution during gastric lavage, the nurse should watch for what complications?
hypothermia
what is your highest priority action for ensuring overall safety during med aministration?
id the pt by 2 acceptable methods
what interventions should a nurse use at mealtimes for a pt who has visual deficits?
identify the food location as though the plate were a clock
an occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. what interventions should the nurse include in the plan of care?
in the event of a dry chemical exposure --> brush the chemical off the skin & clothing
a nurse will be administering several meds to a pt who's receiving enteral feedings through a small bore nasogastric tube. the nurse administers the medications correctly by
infusing each med by gravity and flushing w/ water before and after instillation
a nurse is preparing to administer insulin subcutaneously to a client. the nurse should document the administration of the medication immediately after what action?
injecting the insulin
a pt was admitted to the hospital for same day surgery and has orders for continuous IV therapy. before performing a venipuncture, the nurse should
inspect the iv solution for fluid color, clarity, and expiration date
a nurse is performing a nasogastric intubation. what actions should the nurse take immediately after inserting the tube to the predetermined length?
inspect the oropharynx w/ a penlight & a tongue blade
a nurse is caring for a client who's at high risk for aspiration. what's an appropriate nursing intervention?
instruct the client to tuck her chin when swallowing (allows food to pass down esophagus more easily)
what route of drug administration are there no barriers to absorption?
intravenous
a nurse is likely to receive an order for urinary catheterization of a newly admitted pt who
is in the ICU for a gastrointestinal bleed
nasogastric tube feedings are an appropriate choice for a pt who
is postoperative following laryngectomy
a nurse is applying a condom catheter for an older adult pt who is uncircumcised. what is an appropriate step in the procedure?
leaving a space between the penis & catheter's tip
a nurse is preparing an older adult pt for an enema. the nurse should assist the pt to what position?
left lateral w/ the right leg flexed (makes it easier for enema solution to flow by gravity into the sigmoid & descending colon. flexed leg promotes exposure of the anus for insertion of the rectal tube)
to prevent a common complicate of continuous enteral tube feedings, a nurse should
limit the time the formula hangs to 4 hrs
a nurse who is administering a return-flow enema to a pt should instill 100 mL of enema fluid & then
lower the container to allow the solution to flow back out
while a nurse is administering a cleansing enema, the pt reports abdominal cramping. what is the appropriate intervention?
lower the enema fluid container
while a nurse is administering a cleansing enema, the client reports abdominal cramping. what are appropriate interventions?
lower the enema fluid container (to slow the rate)
what strategies for enhancing the intake of healthful foods is appropriate for an adolescent?
making healthful food choices more convenient & available for the adolescent
a nurse is assessing a pt's indwelling urinary catheter drainage at the end of the shift & notes the output is considerably less than the fluid intake. what should the nurse take first after checking for kinks?
milk the catheter
a nurse is caring for a pt who is on long-term bedrest & requires frequent linen changes due to excessive diaphoresis. what is a priority rationale for frequent linen changes?
moisture from excessive diaphoresis can cause skin breakdown.
a pt w/ a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. what type of feeding tubes is appropriate for the pt?
nasointestinal tube
a nurse is administering aspirin 82 mg PO daily as prescribed. the medication is scheduled for 0800 hours. what demonstrates proper use of one of the 6 rights of med admin?
nurse documents that the aspirin was given at 0825.
a nurse is caring for a client who received lisinopril (Zestril) 30 min ago & is now reporting dizziness & headaches. what actions should the nurse take first?
obtain the client's vital signs
the most reliable method for verifying inital placement of a small-bore feeding tube is by
obtaining an abdominal x-ray
a nurse is preparing to administer a liquid medication to a toddler. what action should the nurse take?
offer the child a choice of taking the medication with either a cup or a spoon
what term indicates a medication is given by injection?
parenteral
a nurse is providing teaching to a pt who is receiving intermittent nasogastric feedings. what should the nurse instruct the pt to report immediately?
persistent coughing
to assess a pt for adequate swallowing, the nurse should do what?
place fingers on the pt's throat at the level of the larynx and ask him to swallow
a nurse is preparing to administer a cleansing enema to a pt who is prone to fecal incontinence d/t poor sphincter control & is unlikely to retain the enema solution. what interventions is appropriate for this pt?
place the pt in the dorsal recumbent position on a bedpan
to prevent aspiration during the administration of an enteral tube feeding, a nurse should
place to pt in Fowler's position
what are some appropriate choices for a pt prescribed a full liquid diet?
plain yogurt, custard, pureed vegetables, gelatin
a client develops dyspnea & feels tired after completing her morning care. what should the nurse include in the client's plan of care for the next day?
plan for several rest periods during morning care
a nurse is teaching a pt how to apply an extended-wear skin barrier. what strategies should the nurse instruct the pt to use for maximal adherence?
press gently around the barrier for 1-2 mins
a pt recovering from gastric surgery remains NPO & has a nasogastric tube connected to suction. what action should the nurse take to prevent dry mucous membranes?
provide frequent mouth care
a nurse is assessing a pt receiving IV normal saline at 125 mL/hr. what should the nurse recognize as a possible complication related to the IV therapy?
pt reports cough and shortness of breath
what is the most appropriate documentation of a pt's response to a pain med?
pt reports pain decreased to 3/10, 30 mins after med administration
a nurse is caring for a pt who has a nasogastric tube connected to suction. what should indicate to the nurse that the tube has become occluded?
pt's report of nausea
a nurse is preparing to instill antibiotic ear drops into a toddler's ear. what techniques should the nurse use when administering ear drops to this pt?
pull the pt's auricle down and back to open the canal when administering ear drops.
while a nurse is teaching a pt how to replace her ostomy pouching system, the pt reports that removing the skin barrier is sometimes painful. what should the nurse suggest?
push the skin away from the barrier while removing it
while performing a complete bed bath for a pt, the nurse should
raise the room temperature
you are giving a pt several po meds to take. the pt tells you that she can only take 1 pill at a time. it's appropriate to
remain at the bedside until you're sure the pt has taken all of the medications
a nurse is providing teaching regarding medication administration to a group of newly licensed nurses. what is a legal responsibility of a nurse?
reporting medication errors
a nurse is caring for a client who is to receive omeprazole (Prilosec) 40 mg PO daily. the client tells the nurse that the pill is too hard to swallow. what action should the nurse take?
request a liquid form of the medication from the pharmacy
a pt who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. the nurse should anticipate receiving an order from the provider for what type of enema?
return-flow (used to expel flatus, stimulate peristalsis, & relieve abdominal distention)
a nurse is preparing to insert an NG tube for a client who requires gastric decompression. what actions should the nurse perform before beginning the procedure?
review a signal the client can use if feeling any distress & lay a towel across the client's chest
a nurse is preparing to administer an insulin injection to a pt. what is appropriate?
rotate injection sites to avoid tissue injury.
a drug's generic name is the
same as its nonproprietary name
a nurse is transcribing a provider's prescription for a client. the prescription reads morphine 2mg IV bolus at 1400. the nurse recognizes this as which of the following types of medication orders?
single order
a nurse is caring for a client who's receiving continuous enteral feedings. what intervention is the highest priority when the nurse suspects aspiration of the feeding?
stop the feeding
a nurse is caring for a pt who has sustained a head injury & whose level of consciousness fluctuates. the provider prescribes a full iquid diet progressing to a pureed diet as tolerated. before initiating feedings, it's essential that this pt undergo what?
swallowing examination
a nurse is providing preoperative teaching for an older adult pt who has diverticulitis & is scheduled for a creation of a double-barrel colostomy in the sigmoid colon. what instructions should the nurse include in the teaching?
tape a dry gauze pad over the distal stoma to collect drainage
a nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. what action by the AP is appropriate?
the AP reuses the pt's blanket & spread.
when providing perineal care for a female pt who has an indwelling urinary catheter, what areas should the nurse cleanse last?
the anus
a nurse is caring for a pt who's receiving D5W w/ 20 mEq of KCL at 75 mL/hr. the provider has prescribed 1 g ceftriaxone (Rocephin) IV. when preparing to administer this med by IV piggyback, what data is the highest priority for the nurse to collect?
the medication's compatibility w/ the primary IV solution
a nurse is performing a nutritional assessment. when obtaining & interpreting anthropometric values, the nurse should recognize what?
the pt should should be weighed on the same scale at the same time each day
a nurse is caring for a client who will perform fecal occult blood testing at home. what information should the nurse include when explaining the procedure to the client?
the specimen cannot be contaminated w/ urine
what is a primary purpose for asking a pt to keep a 3-7 day food diary?
to assess the pattern of intake & compare w/ daily reference intakes
a nurse is preparing to administer an intradermal injection. what should the nurse do to ensure proper technique?
use a tuberculin syringe w/ a 3/8-5/8inch, 25-27 gauge needle
a nurse is caring for a client who's on a low-residue diet. the nurse should expect to see what food on the client's meal tray?
vanilla custard (dairy products & eggs are low in fiber & easy to digest)
a nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. what is the nurse's highest assessment priority before performing this procedure?
verify the placement of the NG tube
a nurse is preparing to given aintramuscular injection into the left ventrogluteal muscle. what should the nurse do to locate the appropriate site?
w/ the heel of the hand on the greater trochanter, point the index finger up toward the anterior superior iliac spine, extending the other fingers back along the iliac crest
a nurse is preparing to administer the first of 2 large-volume, cleansing enemas prescribed for apt in preparation for a diagnostic procedure. what is an appropriate step in the procedure?
warm the enema solution prior to instillation
a nurse is in a client's room preparing to administer docusate sodium (Colace) PO & acetaminophen (Tylenol) PO. the client refuses to take the medications because of nausea. what action should the nurse take?
withhold the medications
a nurse is caring for a pt who has a newly inserted nasogastric tube. what method is appropriate for verifying the initial placement?
x-ray examination of the chest & abdomen
to determine how much of the length of a nasoenteric tube to insert, a nurse should measure the distance from the tip of the pt's nose to the earlobe and from the earlobe to the
xiphoid process plus 20-30 cm more
