Chapter 3

At the end of the shift, a client reports drinking 4 cups of water during the day. The client also has an IV running at 125 mL/hour for the 12 hours. How many mL's of total intake should the nurse document? 960 mL 1500 mL 2460 mL 3960 mL

2460 mL

A patient is receiving a sustained-release capsule for his cardiac condition. The patient tells the nurse there is no way he can swallow such a large pill. What is the best response by the nurse? - "Let me contact your physician to see if a change can be made." - "Place the capsule on the back of your tongue, and drink a full glass of water." - "I will open the capsule and sprinkle the contents over some applesauce for you to eat." - "It may be difficult, but try to swallow the capsule as it is the best medicine for your heart condition."

"Let me contact your physician to see if a change can be made."

The order is for a pain medication to be given intravenous (IV) q 3-4 hours prn. Which statement, by the nurse, correctly teaches the client about this medication order? - "Let me know when you are having pain." - "This medication will be given to you at a set time every day, probably just before your bath." - "You will be given this medication at bedtime each night so that you can rest." - "Always take this medication with food or milk because it might upset your stomach."

"Let me know when you are having pain."

A nurse has finished teaching a client's husband how to administer drugs and enteral feeding through a gastrostomy tube. The nurse knows the husband understands the teaching when he makes which statements? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - "My wife has a gastrostomy tube instead of a nasogastric tube because she will have the tube for a long time." - "I will need to use liquid medications. If any of the medications are in pill form, I will use the pill crusher to crush them and mix them with water before putting them in the tube." - "This medication says it is enteric coated. I'm not supposed to crush this kind of medication. I will need to ask the physician to substitute another medication that is liquid or can be crushed." - "There's a big difference in how the drugs work in the body when they're taken orally and when they're administered through the tube. That's why my wife has to have this tube." - "I have to be very careful to flush the tube after I put medication in it. If I don't, the tube could get clogged."

"My wife has a gastrostomy tube instead of a nasogastric tube because she will have the tube for a long time." "I will need to use liquid medications. If any of the medications are in pill form, I will use the pill crusher to crush them and mix them with water before putting them in the tube." "This medication says it is enteric coated. I'm not supposed to crush this kind of medication. I will need to ask the physician to substitute another medication that is liquid or can be crushed." "I have to be very careful to flush the tube after I put medication in it. If I don't, the tube could get clogged."

A nurse is concerned that a client has not been taking the prescribed antihypertensive medication because the patient's blood pressure remains elevated. What is the best therapeutic response by the nurse? - "Taking medication can be difficult for some people. What are some of your concerns about the medication?" - "Your blood pressure is really high; do you realize the serious consequences of not taking your medication?" - "I really doubt that you are taking your medication. What would you think about talking to the physician?" - "You are one of my favorite patients and I want you to be safe. Are you really taking your medication?"

"Taking medication can be difficult for some people. What are some of your concerns about the medication?"

A client has a prescription for an intravenous medication for nausea. The client asks the nurse how it will help his nausea since it is given in his vein. What is the best therapeutic response by the nurse? - "We have more intravenous drugs for nausea than we do oral drugs." - "If you take an oral medication, you will just vomit it up." - "This will work much faster for your nausea." - "You can't have anything by mouth, so you will receive the medication intravenously."

"This will work much faster for your nausea."

A client will receive a liter of fluid intravenously to treat dehydration. The client says, "I don't understand the metric system, how much is that?" What is the best response by the nurse? - 2 cups - 1 quart - 1/2 gallon - 1000 mL

1 quart

A pediatric client has been receiving 5 mL of liquid antibiotic three times each day. The nurse providing discharge instructions would teach the parents to administer which amount for each dose? - 2 tablespoons - 1 fluid ounce - 15 drops - 1 teaspoon

1 teaspoon

A nurse is caring for the following clients. The nurse should assess for nonadherence with prescribed medications in which clients? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - A 70-year-old male patient with hypertension who has a prescription for a diuretic and is complaining that his medication is keeping him up all night - A 30-year-old college student who has a prescription for birth control pills and tells the nurse she has had breakthrough bleeding this past cycle - A 45-year-old patient with diabetes who has a prescription for insulin and whose blood sugar is within the normal range - A 57-year-old day laborer who has a prescription for Lipitor for high cholesterol and a prescription card for a free health clinic - An 18-year-old male with a prescription for an acne medication that must be taken 4 times a day

A 70-year-old male patient with hypertension who has a prescription for a diuretic and is complaining that his medication is keeping him up all night An 18-year-old male with a prescription for an acne medication that must be taken 4 times a day

A nurse is preparing to administer oral medication to a client. What is the primary nursing assessment of the client prior to receiving this medication? - Understanding of the medication - Ability to swallow - Allergies - Eyesight

Ability to swallow

The nurse plans to administer heparin by drawing the heparin up in an appropriate syringe, donning gloves, prepping the patient's abdominal area, inserting the needle, aspirating for blood, and injecting the medication. Which statement best describes the nurse's plan? A student nurse is administering heparin subcutaneously (SQ) to a client. The nurse should intervene if the student nurse does which of the following? - Apply gloves - Aspirate for blood - Prep the skin with alcohol - Inject at a 45-degree angle

Aspirate for blood

A nurse is preparing to administer a client's medications. Which of the following is most important to assess first? - Assess the patient's developmental level. - Assess the patient's medical history. - Assess the patient's disease process. - Assess the patient's learning needs.

Assess the patient's medical history.

A nurse is preparing to administer a topical medication. What is the priority nursing intervention? - Check the medication for interactions with other medications. - Take the patient's vital signs. - Educate the patient to not disturb the patch. - Assess the patient's skin where the medication will be applied.

Assess the patient's skin where the medication will be applied.

A nurse is observing a student nurse prepare to administer an intradermal medication. Which observation by the nurse indicates the student nurse understands the correct procedure to administer intradermal medications. - Injections should be limited to 1-2 mL. - Avoid sites with excess body hair. - Sites for administration include the upper and lower abdomen. - Medications should be injected into the epidermal skin layer.

Avoid sites with excess body hair.

Twenty minutes after receiving a dose of antibiotic, the client develops a red, itchy rash. What should the nurse do first? - Plan to watch for a rash after the next dose is administered. - Contact the prescriber and relay this assessment information. - Place an allergy bracelet on the patient. - Document the presence of the rash in the medical record.

Contact the prescriber and relay this assessment information.

While in the hospital, a pediatric patient has been receiving amoxicillin 10 mL orally bid, pc. The client will be going home on this medication. What should the nurse include when teaching parents about this medication? - Give 2 teaspoons by mouth, 3 times a day, before meals. - Give 2 teaspoons by mouth, twice a day, after meals. - Give 2 teaspoons by mouth, 3 times a day, after meals. - Give 2 teaspoons by mouth, twice a day, with meals.

Give 2 teaspoons by mouth, twice a day, after meals.

A client has an adverse reaction to a drug following a change in dietary habits. The nurse understands that which change would most likely be the cause? - Increased intake of grapefruit juice - Reduced intake of alcohol - Increased fiber intake - Reduced intake of citrus fruit

Increased intake of grapefruit juice

A nurse is observing a student nurse administer an intramuscular injection in the deltoid muscle. The nurse should intervene if the student nurse does which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - Locates the site by putting the heal of the hand on the greater trochanter. - Selects a 1-inch 23-gauge needle and 3 mL syringe. - Plans to administer 2 mL in a single injection. - Wipes the injection site with an antiseptic wipe. - Inserts the needle at a 45-degree angle with the skin.

Locates the site by putting the heal of the hand on the greater trochanter. Plans to administer 2 mL in a single injection. Inserts the needle at a 45-degree angle with the skin.

A client is 3 days postop, and the physician orders an oral pain medication. The client asks the nurse if it wouldn't be better to get the medication in the intravenous (IV) line. What is the best response by the nurse? - "You could not medicate yourself intravenously (IV) at home." - "Pills are more effective than intravenous (IV) medications." - Pills are safer than intravenous (IV) medications." - "We are going to take your intravenous (IV) line out."

Pills are safer than intravenous (IV) medications."

A nurse is preparing to administer a buccal medication. The nurse should do which of the following? - Place the medication between the cheek and gum. - Instruct the client to swallow the medication. - Apply the medication to clean, dry skin. - Insert the medication under the tongue.

Place the medication between the cheek and gum.

A nurse is preparing to administer several medications for a client. The nurse is responsible for understanding which of the following regarding medication administration? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - Cost of the medication - Reason the medication was prescribed - Route of administration - How the medication is supplied by the pharmacy - Name of the medication

Reason the medication was prescribed Route of administration How the medication is supplied by the pharmacy Name of the medication

A charge nurse is observing a nurse administer an intradermal injection. Which of the following demonstrates that the nurse is using the correct technique? - Selects a 1-inch 23-gauge needle with a 3 mL syringe - Inserts the needle with the bevel down at a 10- to 15-degree angle. - Slowly injects the medication to form a small wheal or bleb. - Withdraws the needle and gently massages the injection site.

Slowly injects the medication to form a small wheal or bleb.

A patient at a community health center has been prescribed oral medications and tells the nurse that medications were administered intravenously when they were in the hospital. The nurse discusses the advantages and disadvantages of oral medications, based on which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - The oral route is considered the second safest route, after the intradermal route. - Tablets that are scored may be crushed for easier swallowing. - Enteric-coated drugs are designed to dissolve in the stomach, not the small intestine. - A major disadvantage of oral medications is that the patient must be conscious and able to swallow. - Enteric-coated drugs should be crushed to help facilitate dissolving by the stomach acid.

Tablets that are scored may be crushed for easier swallowing. A major disadvantage of oral medications is that the patient must be conscious and able to swallow.

A nurse incorrectly administered an oral medication intravenously. What is the best analysis of the nurse's action? - An antidote cannot be given. - The nurse will be terminated from her job. - The medication cannot be retrieved. - A lawsuit by the patient will be impending.

The medication cannot be retrieved.

The patient is having chest pain. The physician orders sublingual nitroglycerine STAT. The nurse obtains the medication from the pharmacy and administers it to the patient 30 minutes later. Which statement best describes the nurse's action? - The medication should have been administered immediately. - The physician should have specified the time frame for the medication. - The medication should have been administered within a 5-minute time frame. - The nursing action was correct because the medication was not on the unit.

The medication should have been administered within a 5-minute time frame.

A nurse administers an oral preparation of liquid acetaminophen 650 mg as ordered. Afterward, the client indicates they have been receiving acetaminophen 650 mg in pill form. Which statement is accurate in regards to the five rights? - The nurse failed to deliver the correct dose. - The nurse failed to administer the right medication. - The nurse did not violate the five rights. - The nurse failed to give the medication via the correct route.

The nurse did not violate the five rights.

A client admitted to the hospital tells the nurse they are very nervous about getting all their medications while they are in the hospital because their healthcare provider has them on a very "strict" schedule. The nurse understands that which of the following describes the principles about how medication dosing schedules are determined? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - The physical and biological characteristics of a drug may determine dosing schedule. - Specific times may improve effectiveness and decrease risk of adverse effects. - Some drugs must be taken a certain time prior to an event or immediately after an event. - Dosing may be set for the convenience of patient and nurse. - Hospitals have routine dosing intervals so that all patients receive medications at the same time each day.

The physical and biological characteristics of a drug may determine dosing schedule. Specific times may improve effectiveness and decrease risk of adverse effects. Some drugs must be taken a certain time prior to an event or immediately after an event. Dosing may be set for the convenience of patient and nurse.

A nurse is preparing medications prior to administration. To promote client safety, the nurse uses the "rights" of drug administration. What do these "rights" include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - The right medication - The right time of delivery - The right dose - The right route of administration - The right nurse

The right medication The right time of delivery The right dose The right route of administration

A nurse is caring for a client who has been involved in a motor vehicle accident. The healthcare provider has written orders for a transdermal patch for pain. The nurse knows which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. - The transdermal patch should not be applied to areas of abrasion. - Transdermal medications undergo the first-pass effect in the liver. - Transdermal medications completely bypass digestive enzymes. - The actual dose received by the patient from this pain patch may vary. - The rate of delivery and actual dose of medications given by the transdermal route can vary.

The transdermal patch should not be applied to areas of abrasion. Transdermal medications completely bypass digestive enzymes. The actual dose received by the patient from this pain patch may vary.

The physician orders enteric-coated aspirin, 300 mg every day, for the patient with a nasogastric tube. What is the priority action by the nurse? - Crush the tablet and administer through the tube. - Put the tablet in the tube and "milk" it down the tube. - Withhold the medication and contact the physician. - Substitute plain aspirin and administer through the tube.

Withhold the medication and contact the physician.