Exam 1

Nurse A is having difficulty logging into the automated medication-dispensing system, and asks Nurse B to log in momentarily so that Nurse A is not delayed in administering client medications. What is Nurse B's appropriate response?

"I will get the hospital's information system's phone number for you."

Z-track injection

*Used for medications that are irritating the tissues. *prevents leakage into the subcutaneous tissue

Three Checks of Medication Administration

1 - take med from package or container (right med & patient) 2 - compare med to EMAR 3 - Before giving medication to client (verify pt & drug against MAR)

In which order should the nurse instruct the client to follow when inserting vaginal medication?

1. Empty your bladder just before inserting the medication. 2. Lubricate the applicator tip with water-soluble lubricant. 3. Lie down, bend your knees, and spread your legs. 4. Separate the labia and insert the applicator into the vagina, and insert the medication. 5. Remain recumbent for at least 30 minutes. 6. Wash and store the reusable applicator properly.

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

10 o 15 degrees

What is the slowest route of absorption?

PO (by mouth) *most common rout of administration

what may put a patient at risk for toxic effects?

Patients with liver problems

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drains are commonly used after a surgical procedure or to drain an abscess.

Therapeutic class

Refers to the clinical indication for the drug or therapeutic action. (What the drug is used for).

Does the route of administration affect absorption ?

The route of administration affects absorption because of the amount of time it takes the medication to absorb. ex. Medications given PO will absorbs slower than medications given IM

A client with a wound infection asks the nurse, "What causes this puslike drainage in my wound?" Which response by the nurse would be most appropriate?

Your white blood cells have increased in the area. Purulence or pus in an area of infection results from the migration of white blood cells to the area of infection. Purulent drainage is usually thicker than normal and is often foul smelling because it contains a great deal of cellular debris from the inflammatory response.

For which clients would the nurse be required to use droplet precautions? Select all that apply.

a client with rubella a client with mumps a client with diphtheria prioritization

ADR

adverse drug reaction. Harmful effects that lead to injuries. ex. allergic reaction

pc

after meals

prn

as needed

ac

before meals

Buccal

between the gums and cheek * more rapid absorption due to the superficial blood vessels

The nurse has completed administering medications through an enteral tube used for decompression. What is the appropriate nursing action?

clamp the tube for at least 30 minutes

Jackson-Pratt drain

collects wound drainage in a bulblike device that is compressed to create gentle suction, consists of perforated tubing connected to a portable vacuum unit, typically used with breast and abdominal surgery, care-- usually drains are changed every 4 to 8 hrs, and when they are half full of drainage or air,

IM injection sites

deltoid *1mL max vol ventrogluteal *1-3mL max vol vastus lateralis *1-3ml max vol

q2h

every 2 hours

qh

every hour

qn

every night

what causes c-diff?

excessive antibiotic use

qid

four times a day

urticaria

hives

Intramuscular (IM)

injection into a muscle. *90 degrees *22-25 gauge *1 to 1.5 in

intradermal injection

injection placed into the dermis just below the epidermis. *5-15 degree angle *26 to 27 gauge *1/4 - 1/2 in * 0.5mL max

transdermal medication

medication absorbed through intact skin

Absoprtion

process by which drugs are transferred from the site of entry into the body to the bloodstream

A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?

vastus lateralis site The vastus lateralis site is most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles. The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed.

A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?

ventrogluteal

Dry dressing

woven gauze or sponge (absorbs drainage)

Med administration via Gastrointestinal tubes

* Check tube placement * Use liquid medication when possible. Flush w/ water before and after administration. * Crush meds and mix with liquid usually at room temp(15-30mL). * Capsules *Elevate the head of the bed

How are ear drops administered?

* Patient sits up or lies on their side * Adults: Straighten ear canal by pulling auricle up and out *Children: Pull auricle down and back for children.

What is the nurse responsible for when checking orders?

1. Verifying the original order was transcribed correctly. 2. Double checking dosage and appropriateness of the medication *the nurse is legally responsible for the drug the administer.

where should eye drops be administered?

2cm above the conjunctival sac(drops go in the center of the sac)

How long should you wait in-between eye medications?

5 minutes

The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear?

5 minutes

ACE inhibitors

Angiotensin-Cnverting Enzyme. Helps the body produce less angiotensin helping the blood vessels relax-and open-up. ACE inhibitors help with hypertension

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

Dehiscence

Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. Localized dehydration

The nurse is preparing a sterile field for a procedure in the client's presence. Which is the most appropriate instruction to give the client in this situation?

I have set up this sterile field for your procedure, so please do not touch anything around the tray.

The nurse has given medications to four clients. Which client will the nurse monitor most closely for a possible reaction to occur?

Nurses carefully monitor all clients and know that reactions are more likely to occur when something is given intravenously. Therefore, the nurse will most closely monitor the client who received a bolus of Lactated Ringer's solution.

Types of Orders

Standing order, PRN order, single order, stat order

A nurse is caring for a 6-year-old client on the hematology-oncology floor. During a packed red blood cell (PRBC) transfusion, the client reports of pain at the peripheral IV site. The nurse assesses the site and notices that the site is purple. What is the nurse's best course of action?

Stop the transfusion and insert peripheral IV at a new site. Pain and a purplish bruise at the IV site are signs of infiltration. Infiltration with PRBCs will give the appearance of a bruise.

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T-lymphocytes Neutrophils are phagocytes that ingest and break down foreign particles and act as an important link in generating fever. Eosinophils are involved in allergic reactions. Monocytes are scavenger cells that dispose of cellular debris.

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

The client may be experiencing a life-threatening reaction to the antibiotic. The nurse should clamp the secondary infusion line which is infusing the antibiotic and notify the primary care provider immediately. It would be inappropriate for the nurse to flush the PICC line as this will increase the amount of antibiotic getting into the client's body. Slowing the infusion rate will also not correct or prevent further adverse effects. The nurse should not remove the PICC line as this may be outside the nurse's scope of practice as it requires special training and certification to do that.

what are the components of an order?

The components of an order include the client's name, the medication name, the amount and frequency of the dose, and the route of administration.

The nurse is caring for a client who has normal saline infusing through a peripheral intravenous catheter with a prescription for a secondary infusion of antibiotic. Which technique would be most appropriate for the nurse to administer the secondary infusion by gravity?

The nurse should place the secondary infusion higher than the primary infusion. This will allow the secondary infusion to infuse first. When completed, the primary infusion will continue to infuse. The other options are not correct.

The rapid response team is present while a client is receiving cardiopulmonary resuscitation (CPR). The health care provider informs the nurse to administer a dose of epinephrine IV. Which method of medication will the nurse obtain?

The nurse will need to obtain the medication rapidly because this is an emergency situation. The fastest method in this scenario is the stock supply, which is a large number of stored drugs that remain on the unit for emergency use.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin.

percutaneous endoscopic gastrostomy tube (PEG)

a feeding tube inserted endoscopically into the stomach

antagonist effect

a type of drug reaction that decreases or negates the effect of the other.

Where does metabolism of medication occur? And what happens to the medication.

liver, medication goes from active to inactive.

NEB

nebulizer

distrubution

occurs after a drug has been absorbed into the bloodstream

toxic effect

occurs from a cumulative effect of a drug in the body. The body is unable to metabolize one dose before another dose. Creates toxic drug levels in the body.

6 rights of medication administration

patient, time, dose, route, medication, documentation

pr

per rectum

Following a demonstration to a family member on how to insert a straight catheter, the nurse instructs the family member to remove the gloves by inverting one glove into the other. Which step would the nurse instruct the family member to do next?

perform hand hygiene

Excretion

process of removing the dug from the body. Kidneys are the primary site for excretion.

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

pull the clients ear up and back

debridement

removal of foreign material and dead or damaged tissue from a wound

The largest organ in the body

skin

SL

sublingual (under the tongue)

s & s

swish and swallow

Z-track technique

technique used to administer medications intramuscularly that ensures that the medication does not leak back along the needle track and into the subcutaneous tissue, reducing pain and discomfort

The nurse prepares to administer an intravenous medication. Which action should the nurse perform when administering a medication from an ampule?

the ampule should be broken away from the nurse's body to prevent being cut by the broken glass. The nurse should wrap sterile gauze pad around the neck to make a sufficient barrier so broken glass particles don't easily cut the nurse. An alcohol pad may slip and does not provide adequate padding. The filter needle is attached when drawing up the medication from the ampule to prevent small glass particles in the syringe. The nurse would change the needle to the needless system to inject it intravenously. The nurse should insert the tip of the filter needle into the center of the ampule and invert the ampule to draw up the medication.

Metabolism (biotransformation)

the change from an active drug from its original form to an inactivated form. The liver is primary site for drug metabolism.

nomenclature

the devising or choosing of names for things. (Brand Names)

Pharamacokinetics

the effect the body has on a drug once the drugs enters the body. (The movement of the drugs in the body).

subcutaneous

the layer below the epidermis and dermis of the skin; adipose *45 degrees *23-25 gauge 3/8 to 5/8 in *1mL max

pharmaceutical class

the mechanism of action, physiologic effect, and chemical structure of the drug. (This is what the drug does).

tid

three times a day

jejumostomy tube

tube inserted through the abdominal wall directly into jejunum(small portion of the small intestine).

nasointestinal tube

tube inserted through the nose and into the upper portion of the small intestine

nasogastric tube

tube inserted through the nose into the stomach

bid

twice a day

biw

twice a week

Hemovac drain

typically placed into a vascular cavity where blood drainage is expected after surgery

The most lethal infection in an older adult client is:

urinary Urinary tract infections and respiratory infections are most common and most lethal for older adult clients.

synergistic effect

when drugs taken together potentiate effects of others