Fundamentals Exam #2
what are the 3 checks?
1. verifying that the label of the medication matches the MAR 2. preparing the med and again checking the medication label against the MAR 3. recheck of the medication label a final time against the MAR before opening the package at the bedside
an average daily urine output is __________ mL
1440 mL
A nurse must give 1 g of Keflex, PO, q 6 hr 3 days. The supply on hand is 500 mg/capsule. How many capsules should the nurse administer at each dose?
2 CAPSULES
A patient in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing assistant in the appropriate care to provide. The nurse teaches the assistant to : a. empty the drainage bag when 2/3 full b. cleanse up the length of the catheter to the perineum c. open the drainage system to obtain a specimen for culture and sensitivity d. place the drainage bag on the patient's lap while transporting the patient to testing
A
A patient is going to have an IVP. Which of the following reflects the most critical assessment question for this patient before the procedure? a. "are you allergic to iodine?" b. "did you remove all metal?" c. "have you had this procedure before?" d. "when did you last have a procedure that required sedatives?"
A
A patient is receiving closed catheter irrigation. During the shift, 950 mL of normal saline irrigant aare instilled, and there is a total of 1725 mL in the drainage bag. The patient's urinary output is calculated by the nurse to be: a. 775 mL b. 950 mL c. 1725 mL d. 2675 mL
A
A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet
A
A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes: A. Tracheal suctioning. B. Oropharyngeal suctioning. C. Nasotracheal suctioning. D. Orotracheal suctioning.
A
A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. check to see if the catheter is present b. reassure the patient that it is not possible to void while catheterized c. catheterize the patient again with a larger--gauge catheter d. notify the PCP
A
A patient with chronic pneumonia may be evaluated by a speech therapist for which cause? a. Chronic aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scolioses
A
A timed urine specimen collection is ordered. The test will need to be restarted if the: a. patient voids in the toilet b. urine specimen is kept cold c. first voided urine is discarded d. preservative is placed in the collection container
A
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient's medication drawer. What should the nurse in charge do? a. Discard the syringe to avoid a medication error. b. Obtain a label for the syringe from the pharmacy. c. Use the syringe because it looks like it contains the same medication the nurse was prepared to give. d. Call the day nurse to verify the contents of the syringe.
A
If a nurse experiences a problem reading a physician's medication order, the most appropriate action will be to: A. Call the physician to verify order. B. Call the pharmacist to verify order. C. Consult with other nursing staff to verify. D. Withhold the medication until physician makes rounds.
A
In an assessment of a patient with overflow incontinence, the nurse expects to find that the patient has: a. a constant dribbling of urine b. no urge to void and an unawareness of bladder filling c. an uncontrollable loss of urine when coughing and sneezing d. an immediate urge to void but not enough time to reach the bathroom
A
Nursing interventions for the patient who suffers from stress incontinence include a. kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.
A
The client asks the nurse recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse? a. Whole grains b. Fruit juice c. Rare meats d. Milk products
A
The client is admitted to the emergency department with a pneumothorax. The nurse anticipates that the client will be experiencing: A. Dyspnea B. Eupnea C. Fremitus D. Orthopnea
A
The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the follow interventions does the nurse plan to include in the client's care? A. Assess nares for skin breakdown every 6 hours B. Check patency of the cannula every 2 hours C. Inspect the mouth every 6 hours D. Check oxygen flow every 24 hours
A
The finding of a barrel chest configuration in a patient may be related to which of the following disorders? a. Chronic obstructive pulmonary disease b. Acute asthma attack c. Cardiomyopathy d. Acute myocardial infarction
A
The home health nurse is called for a consult on a patient with memory problems who is having difficulty remembering to take multiple medications prescribed to be taken throughout the day. What can the nurse do to help the patient remember to take the medications as prescribed? a. Arrange for the medications to be put in a pill organizer by week. b. Make a chart showing times when medications should be taken. c. Ask a family member to come over each day to administer medications. d. Ask the patient to set an alarm clock for when medications are due.
A
The nurse is about to administer a new medication to a patient. Which action best demonstrates awareness of safe, proficient nursing practice? a. Identify the patient by comparing her name and birth date to the medication administration record (MAR). b. Determine whether the medication and dose are appropriate for the patient. c. Make sure the medication is in the medication cart. d. Check the accuracy of the dose with another nurse.
A
The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. Which type of renal failure did the patient most likely develop? a. Prerenal b. Renal c. Post-renal d. Mixed
A
The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action should the nurse take next? a. Notify the primary care provider to place a coudé catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage.
A
The nurse is instructing the client in stomal care for an incontinent ostomy. The nurse evaluates achievement of learning goals if the client uses: a. cuts the opening 1/16 inch larger than the stoma b. Peroxide to toughen the periostomal skin c. A commercial deodorant around the stoma d. Alcohol to cleanse the stoma
A
The nurse is preparing a plan of care for a patient. What is the most appropriate goal for a patient related to medications? a. The patient will administer all medications correctly by discharge. b. The patient will be taught common side effects of prescribed medications. c. The patient will have a good understanding of prescribed medications. d. The patient will have all medications administered by staff as prescribed.
A
The nurse suspects that the patient has a bladder infection on the basis of the patient exhibiting: a. nausea b. hematuria c. flank pain d. incontinence
A
The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation.
A
The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal
A
Which of the following drug types is dissolved in a solution of alcohol and water? Elixir Liniment Emulsion Syrup
A
Which of the following urinary diversions requires that the patient has a stoma created? a. Ileal conduit b. Kock pouch c. Mainz pouch d. Ileal neobladder
A
Which organism is responsible for the majority of urinary tract infections in female patients? a Escherichia coli b. Nesseria gonorrhea c. Candida albicans d. Haemophilus influenza
A
a medication order that is to be administered immediately is: a. diapam 10 mg IV stat b. lanoxin 0.125 mg PO daily c. ibuprofen 300 mg q4h prn d. ativan 1 mg IV on call for surgery
A
a priority for the nurse in the administration of oral med and prevention of aspiration is: a. checking for a gag reflex b. assessing the ability to cough c. allowing the patient to self-administer d. using straws and extra water for administration
A
an order is written by the prescriber for Demerol 500 mg IM q3-q4h prn for pain. the nurse recognizes that this is significantly more than the usual therapeutic dose. the nurse should: a. call the prescriber to clarify the order b. give 50 mg IM as it was probably intended to be written c. refuse to give the med and notify the nurse manager d. administer the med and watch the patient carefully
A
for the patient with an ileostomy, the critical element is: a. skin care b. odor control c. stoma irrigation d. infection prevention
A
the nurse instructs the patient that, before the fecal occult blood test, she may eat: a. whole wheat bread b. lean steak c. grapefruit d. beets
A
the nurse is aware that normal bowel sounds are: a. high-pitched and irregular b. occurs every 5-10 minutes c. absent between sounds d. loud and slow
A
the patient asks the nurse about different herbal therapies that may promote physical stamina and mental concentration. on the basis of the patient's request, the nurse provides information on: a. ginseng b. ginger c. echinacea d. chamomile
A
the patient is to receive a medication via buccal route. the nurse plans to implement which of the following actions a. place the med inside cheek b. crush the med before administration c. utilize sterile technique to administer the med d. offer the patient a glass of orange juice after administration
A
the patient receiving an IV infusion of morphone sulfate begins to experience respiratory depression and decreased urine output. this effect is described as: a. toxic b. allergic c. therapeutic d. idiosyncratic
A
The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this patient? (Select all that apply.) a. Vomiting b. Unconsciousness c. Fractured leg d. Penicillin allergy e. Family visitor f. Diarrhea
A, B
the nurse is to administer medications through the patient's NGT. which of the following techniques is/are correct. select all that apply a. check the placement of the tube before giving medications b. crush al the patient's tablets and capsules c. flush the tube before and after with 5 mL of water d. have the patient sit upright for the medication administration e. keep the patient's head elevated after the administration for at least 30 minutes f. replace gastric suction, if used, right after giving the medication
A, D, E
When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine (Pyridium) b. A diet that includes a large amount of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake
A,B,C,D
When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? Select all that apply. a. Taking the urinary tract analgesic phenazopyridine (pyridium) b. a diet that includes a large amount of beets or blackberries c. an enlarged prostate or kidney stones d. high concentrations of bilirubin secondary to liver disease e. increased carbohydrate intake
A,B,C,D
Which questions are included in a focused history for a cardiac patient? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?
A,B,D,E
The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the physician to obtain an order for urine culture and sensitivity testing? (Select all that apply.) a. Urinary dipstick testing is positive for nitrates. b. The urine appears cloudy with a foul odor. c. The urine is concentrated and dark amber in color. d. The urine smells faintly like nail polish remover. e. The patient is urinating more frequently than usual. f. The patient is normally continent but wet herself twice.
A,B,E,F
Prior to discharge, the nurse teaches the patient the proper techniques for applying an ostomy pouch. When evaluating the teaching, the nurse observes the patient apply a new ostomy pouch without cleansing the skin underneath. What action(s) should the nurse implement following this patient's return demonstration? (Select all that apply.) a. Repeat the demonstration to show the patient how to clean the ostomy site. b. Document that the patient performed the initial return demonstration accurately and safely. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. e. Notify the health care provider that a repeat demonstration of the ostomy appliance procedure is needed.
A,C,D
To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake
A,C,D,E
which of the following is the most effective way in the acute care environment to determine the patient's identity before administering medications. select all that apply a. check the patient's medical record number on the ID band b. use the patient's room number c. compare an ID photo with the patient d. check the patient's date of birth e. use the bar code system, if available f. call the patient by name
A,C,D,E
The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties. Which action by the nursing assistant indicates that additional teaching is required so that the assistant will learn to care for patients correctly? (Select all that apply.) a. The length of the urinary catheter is cleaned up to the patient's perineum. b. A urine sample is obtained from the drainage bag immediately after catheter insertion. c. A fresh condom catheter is applied every other day following careful perineal care. d. Zinc oxide barrier cream is applied liberally to the perineal area for incontinent patients. e. The catheter drainage bag is disconnected in order to put pants on the patient. f. Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter.
A,C,E,F
The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply.) a. Patency of the balloon is tested prior to insertion of the catheter. b. The catheter is inserted another 2 inches after urine is seen in the tubing. c. The catheter is carefully secured to the leg to prevent accidental removal. d. The foreskin is returned to its natural position after the catheter is removed. e. Catheterization is performed regularly before the bladder becomes distended. f. Water-soluble lubricant is generously applied along the length of the catheter.
A,C,F
A patient has been using herbal medication as part of her daily routine. Which actions should the nurse take? (Select all that apply.) a. Document the herbs as part of the medication history. b. Recommend a reputable company from which to buy herbs. c. Allow the patient to self-administer the herbs with her morning medications. d. Inform the health care provider of the findings. e. Identify possible adverse effects of the herbal medications.
A,D,E
Which of the following individuals may be more prone to episodes of urinary incontinence? Select all that apply. a. women b. men c. school aged children d. older adults e. pregnant women
A,D,E
what are expected characteristics of urine. select all that apply. a. pale yellow color b. cloudy c. fruity odor d. pH=6 e. protein present f. no glucose
A,D,F
When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Perform hand hygiene and apply sterile gloves. c. Add room-temperature solution to enema bag. d. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. e. Raise container, release clamps, and allow solution to flow to fill tubing. f. Hang solution bag 45 to 60 cm (18 to 21 inches) above anus and instill rapidly. g. Clamp tubing after solution is instilled
A,E,G
medication enema
Antibiotic enemas used to treat local infections (worms, parasites); a type of retention enema
2. A 6-month-old infant has severe diarrhea. The major problem associated with severe diarrhea is: a. Pain in the abdominal area b. Electrolyte and fluid loss c. Presence of excessive flatus d. Irritation of the perineal and rectal area
B
A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Altered Skin Integrity b. Risk for Imbalanced Fluid Volume c. Acute Pain d. Self-Care Deficit: Toileting
B
A flow rate of oxygen of 2 L per minutes is providing what percent of oxygenation? a. 24% b. 28% c. 32% d. 36%
B
A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: A. Abnormal defecation. B. Constipation. C. Fecal impaction. D. Fecal incontinence.
B
A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. home care nurse b. wound ostomy continence nurse c. registered dietitian d. primary care provier
B
A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis showing negative results on testing for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination
B
A patient is scheduled for an intravenous pyelogram. Which piece of data would be most important to know before the procedure is carried out? a. urinalysis showing negative results on testing for sugar and acetone b. history of allergies c. history of recent thyroid scan d. frequency of urination
B
A sample is obtained from the patient for a routine urinalysis. After reviewing the results of the test, the nurse notes that an expected finding of the urinalysis is: a. pH 8.0 b. specific gravity 1.018 c. protein amounts to 12 mg/100mL d. WBCs of 5 to 8 per low-power field casts
B
An alcohol extract of a therapeutic material is known as a(n) a. elixir. b. tincture. c. emulsion. d. suppository.
B
An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure
B
An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse preforming the procedure? a. teaching deep-breathing techniques b.maintaining strict aseptic technique c. medicating the patient for pain before the procedure d. positioning the patient for comfort during the procedure
B
Average urine pH is a. 4 b. 6 c. 7 d. 9
B
Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following? A. Medication before administering it B. Medication after administering it C. Rationale for administering it D. Prescriber rationale for prescribing it
B
The client has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the client may experience that the nurse is alert to is: A. Jugular neck vein distention B. Pulmonary congestion C. Peripheral edema D. Liver enlargement
B
The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to: A. Suction continuously for 30 second intervals B. Replace the oxygen and allow rest in between suctioning passes C. Increase the amount of suction pressure to 200 mmHg D. Complete a number of suctioning passes until the catheter comes back clear
B
The client is seen in the gastroenterology clinic after having experienced changes in his bowel elimination. A colonoscopy is ordered and the client has questions about the examination. Before the colonoscopy, the nurse teaches the client that: a. No special preparation is required b. Light sedation is normally used c. No metallic objects are allowed d. Swallowing of an opaque liquid is required
B
The exchange of oxygen and carbon dioxide occurs in the alveoli. How is oxygen carried in the blood? a. The white blood cells b. The hemoglobin c. The platelets d. The neutrophils
B
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? a. A ratio of 1:2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine
B
The nurse assessing a patient withan indwelling catheter and finds that the catheter is not draining and the patient's bladderis distended. What action should the nurse take next? a. notify the PCP b. assess the tubing for kinks and ensure downward flow c. change the catheter as soon as possible d. aspirate the stagnant urine in the catheter for culture
B
The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider (PCP). b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.
B
The nurse is caring for a patient with a history of incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis of Ineffective therapeutic regimen management? a. The patient will be provided with educational materials about risks of urosepsis. b. The patient will allow family members to assist with daily bathing and perineal care. c. The patient will clearly state why she refuses to provide adequate care for herself. d. Regular home care nursing visits and follow-up telephone contact will be arranged.
B
The nurse is placing an indwelling catheter in a female patient. She inserts the catheter into the vagina. What is the next action for the nurse to implement? a. collect a urine specimen and notify the PCP b. leave the catheter in place and insert a new catheter into the urethra c. remove the catheter from the vagina and place it into the urethra d. ask another nurse to attempt the catherization of the patient
B
The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the clients, which is: A. Cyanosis B. Restlessness C. A decreased respiratory rate D. A decreased blood pressure
B
The nurse is working on a respiratory care unit in the hospital. Upon entering the room of a client with emphysema, it is noted that the client is experiencing respiratory distress. The nurse should: A. Instruct the client to breathe rapidly B. Provide 20% oxygen at 2 L/min via nasal cannula C. Place the client in the supine position D. Go to contact the health care provider
B
The nurse is working with a patient who has an incontinent urinary diversion. Included in the plan of care for this patient is instruction that: a. special clothing is necessary b. careful skin care is a priority c. a stoma bag will only need to be worn at night d. a strict reduction in physical activity will be planned
B
To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. The presence of food stimulates peristalsis. B. Mass colonic peristalsis occurs at this time. C. Irregularity helps to develop a habitual pattern. D. Neglecting the urge to defecate can cause diarrhea.
B
Urinary elimination may be altered with different pathophysiological conditions. For the patient with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be which of the following? a. urgency b. polyuria c. dysuria d. hematuria
B
What should the nurse do first when preparing to administer medications to a patient? a. Check the medication expiration date. b. Check the medication administration record (MAR). c. Call the pharmacy for administration instructions. d. Check the patient's name band.
B
When evaluating a post-thoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to: A. Strip the chest tube every hour to maintain drainage. B. Place the device below the patient's chest. C. Double clamp the tube except during assessment. D. Remove the tubing from the drainage device to check for proper suctioning.
B
Which is a goal for a patient with the nursing diagnosis of Ineffective Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase to 28 breaths/min during hospitalization.
B
Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. tell the patient to void and pour the urine into a labeled specimen container b. ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container c. instruct the patient to discard the first void and collect the next void for the specimen d. have the patient keep all voided urine for 24 hours in a chilled, opaque collection container
B
Which of the following is a recommended immunization for adults yearly? a. Pneumococcal b. Influenza c. Polio d. Tetanus
B
Which situation contributes to cyanosis in the pulmonary patient? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels
B
While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: a. Immediately stop the infusion b. Lower the height of the enema container c. Advance the enema tubing 2 to 3 inches d. Clamp the tubing
B
a patient has a prescription for a med via an inhaler. in order to determine if the patient requires a spacer for the inhaler, the nurse will determine the: a. dosage of med required b. ability of the patient to control the rate of inhalation c. schedule of administration d. use of a dry powder inhaler (DPI)
B
a small-volume enema that is used to provide relief from gastric distention and stimulate peristalsis ia a: a. hypertonic enema b. carminative enema c. oil retention enema d. medication enema
B
all of the following patients are expericing increased respiratory secretions and require intervention to assist in their removal. chest percussion is indicated and apprpriate for the patient experiencing which of the following? a. thrombocytopenia b. cystic fibrous c. osteoprosis d. spinal fracture
B
an order is written for 80 mg of a med in elixir form. the med is available in 80 mg/tsp strength. the nurse prepares to administer how much: a. 2 mL b. 5 mL c. 10 mL d. 15 mL
B
the nurse is working on the pediatric unit. in preparing to give a med to a preschool age child, an appropriate interaction by the nurse is: a. "do you want to take your med now" b. "would you like the med with water or juice" c. "let me explain about the injection that you will be getting" d. "if you don't take the med now you will not get better"
B
the nurse prepares to administer an ID injection for the administration of med for: a. pain b. allergy sensitivity c. anticoagulant therapy d. low-dose insulin requirements
B
the patient has experienced a myocardial infaraction resulting in damage to the left ventricle. a possible complication the patient may experience that the nurse is alert to is: a. jugular neck vein distention b. pulmonary congestion c. peripheral edema d. liver enlargement
B
the patient is taking a herbal remedy for mild anxiety and difficulty sleeping. it also has the potential to interact with antidepressant medications. the nurse expects that this patient is taking: a. chamomile b. st. johns wort c. echinacea d. gingko biloba
B
which of the following is a correct technique for use of an insulin pen a. clean the pen tip with household soap b. prime the pen with 2 units before use c. cover the needle until the next dose d. empty the pen and complete the dosage with a new pen if necessary
B
which one of the following actions performed by the new staff nurse and observed by the nurse manager requires additional instructions? a. giving medications 20 minutes before the scheduled time b. applying a topical medicated cream without gloves c. alternating the side of the cheeks for buccal medications d. documenting on the MAR that the patient refused the medication
B
Identify the topical medication route(s). Select all that apply. A. Cough suppressant B. Vaginal suppository C. Transdermal patch D. Patent-controlled analgesia drip E. Ear irrigation F. Antiseptic throat spray
B, C, E, F
indicate the possible causes of diarrhea. select all that apply a. reduced fluid intake b. food-borne pathogens c. hypothyroidism d. low-fiber diet e. psychological stress f. administration of narcotic analgesics
B, E
The nurse is caring for a patient who is to complete a 24-hour urine collection to measure creatinine clearance. Which tasks related to this test may be delegated to the nursing assistant? (Select all that apply.) a. Teaching the patient about sterile specimen collection b. Keeping the urine collection container cool on ice c. Dumping the urine from the patient's first void d. Restricting the patient's oral fluid intake during the test e. Transporting the specimen to the laboratory for testing f. Reminding the patient not to put toilet paper in the urine
B,C,E,F
A client with a chest tube in place is being transported via stretcher to another room closer to the nurses' station. During the transport, the collection unit bangs against the wall and breaks open. The nurse immediately: A. Clamps the tube B. Tells the client to hyperventilate C. covers the site with an occulusive dressing D.pushes the tube back into the chest opening
C
A condom catheter is to be used for an adult male patient in the extended care facility. In the application of the condom catheter, the nurse employs appropriate technique when: a. using sterile gloves b. wrapping adhesive tape securely around the base of the penis c. leaving a 1 to 2 inch space between the tip of the penis and the end of the catheter d. taping the tubing tightly to the thigh and attaching the drainage bag to the side rail
C
A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."
C
A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the: A. Bladder. B. Kidney. C. Nephron. D. Ureter.
C
A patient with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). The nurse anticipates the patient will exhibit: a. hematuria b. an increased blood pressure c. dry mucous membranes d. a low serum sodium level
C
A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels
C
A postpartum patient has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the patient initially? a. increase fluid intake to 3500 mL b. insert an indwelling catheter c. rinse the perineum with warm water d. apply firm pressure over the bladder
C
A toileting program for a patient in an extended care facility should include which of the following? a. providing negative reinforcement when the patient is incontinent b. having the patient wear adult diapers as a preventative measure c. putting the patient on a q2h toilet schedule during the day d. promoting the intake of caffeine to stimulate voiding
C
An order is written for the patient's indwelling urinary catheterization to be discontinued. The unit manager is observing the new staff nurse provide care to this patient and implement the prescriber's order. The unit manager determines that further instruction is required for the new staff nurse in catheter removal if he is observed: a. draping the female patient b. obtaining a specimen before removal c. cutting the catheter to deflate the balloon d. checking the patient's output carefully for 6 to 8 hours after removal
C
For clients with hypocalcemia, the nurse should implement measures to prevent: a. Gastric upset b. Malabsorption c. Constipation d. Fluid secretion
C
In determining the patient's urinary status, the nurse anticipates that the urinary output for an average adult should be approximately: a. 400 mL/day b. 800 mL/day c. 1400 mL/day d. 2000 mL/day
C
In teaching a client about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material? A. Holter monitor B. Echocardiography C. Cardiac catheterization D. Exercise stress test
C
It is suspected that the client's oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client's decreased oxygenation is: A. Poor skin turgor B. Clubbing of the nails C. Central cyanosis D. Pursed-lip breathing
C
Kefauver-Harris drug Amendment were passed in 1962 in order to: a. classify habit-forming medications as narcotics b. mandate accuracy in drug labeling c. require proof of drug safety and efficacy before marketing d. categorize drugs on their abuse and addiction potential
C
On admitting a client, the nurse finds that there is a history of myocardial ischemia. The most disconcerting dysrhythmia for electrocardiography to reveal is: A. Sinus bradycardia B. Sinus dysrhythmia C. Ventricular tachycardia D. Atrial fibrillation
C
The client has been admitted to an acute care unit with a diagnosis of upper GI bleeding. The nurse suspects that the feces will appear: a. Bloody b. Pus filled c. Black and tarry d. White or clay colored
C
The health care provider prescribes a medication that is administered transdermally. The nurse understands what feature of the transdermal route? a. It is inhaled into the respiratory tract. b. It is dissolved inside the cheek. c. It is absorbed through the skin. d. It is inserted into the vaginal cavity.
C
The nurse is caring for a patient who is unable to hold a cup or spoon. How should the nurse administer oral medications to the patient? a. Crush the pills and mix them in pudding before administering. b. Ask the pharmacist to change all of the medications to a liquid form. c. Use a small paper cup to put the pills into the patient's mouth. d. Place the pills on the table and have the patient take the pills by hand.
C
The nurse is caring for clients on a postoperative unit in the medical center. The nurse is alert to the possibility that for 24 to 48 hours of the postoperative period, clients may experience the following as a result of the anesthetic used during the surgery: a. Colitis b. Stomatitis c. Paralytic ileus d. Gastrocolic reflex
C
The nurse is selecting a site to administer a medication by the intramuscular route. The nurse chooses to avoid which site due to the high risk for injury? a. Vastus lateralis b. Ventrogluteal c. Dorsogluteal d. Deltoid
C
The nurse is teaching a patient about how to take a sublingual nitroglycerin tablet. Which statement by the patient best demonstrates understanding of the teaching? a. "I will hold the tablet next to my skin." b. "I will put the tablet inside my cheek." c. "I will put the tablet under my tongue." d. "I will place the tablet in the lower lid of my eye."
C
The nurse reviews a physician's order and finds that the medication amount it greater than the standard dose. What should the nurse do? a. give the standard dose rather than the one that is ordered b. inform the nursing supervisor c. call the physician to discuss the order d. give the drug as ordered by the physician
C
The nursing instructor is evaluating the student during the catheterization of a female patient. The instructor determines that the student has implemented appropriate technique when observed: a. keeping both hands sterile throughout the procedure b. reinserting the catheter if it was misplaced initially in the vagina c. inflating the balloon to test it before catheter insertion d. advancing the catheter 7 to 8 inches
C
To best determine the patient's competency in changing an ostomy appliance, what should the nurse ask the patient to do? a. Verbalize the procedure. b. Identify the supplies needed. c. Perform the procedure. d. List the steps in the procedure.
C
What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. change the appliance before going to bed b. cut the water 1 inch larger than the stoma c. cleanse the peristomal skin with mild soap and water d. use firm pressure to attach the wafer to the skin
C
What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.
C
What should be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his or her routine d. Knowing the difference between laxatives and cathartics
C
Which action does a nurse anticipate when suctioning a patient with excessive secretions? a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Avoid lubricating the catheter tip to prevent getting the substance in the lung tissues. c. Limit the time that the catheter is suctioning to prevent excessive loss of oxygen during the process. d. Flush the artificial airway with 3 mL of tap water to loosen secretions before suctioning.
C
Which discharge instruction should the nurse provide to the patient following a colonoscopy? a. Some discomfort and bleeding is normal postprocedure. b. Return to the emergency room if you experience mild abdominal cramping. c. Do not drive or operate heavy machinery for 12 hours postprocedure. d. Return to your normal bowel pattern immediately postprocedure.
C
Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise
C
Which of the chambers of the heart becomes enlarged when mitral valve stenosis occurs? a. Right atrium b. Right ventricle c. Left atrium d. Left ventricle
C
Which of the following oxygen masks has holes at the side that allow air to enter the mask? a. Partial rebreathing mask b. Nonrebreathing mask c. Simple face mask d. Nebulizer mask
C
Which statement by the patient about herbs and prescription medications demonstrates understanding of education by the nurse? a. "I can stop taking my prescription medication when I begin an herbal preparation." b. "I know that herbal preparations are highly regulated in this country to ensure no interactions with prescription medications." c. "I should check with my physician before beginning an herbal preparation." d. "I cannot ever take an herbal preparation while I am using prescription medication."
C
a med is prescribed for the patient and is to be administered by IV bolus injection. a priority for the nurse before administration of med via this route is to: a. set the rate of the IV infusion b. check the patient's mental alertness c. confirm placement of the IV line d. determine the amount of IV fluid to be administered
C
an older patient has developed kyphosis and is at a greater risk for developing pneumonia primarily because the: a. resulting paralysis immobilizes him and secretions will increase in his lungs b. innervation to the phrenic nerve is absent, preventing chest expansion c. abnormal chest shape prevents efficient ventilatory movement d. trauma decreases the ability of his red blood cells to carry oxygen
C
following the administration of eardrops to the left ear, the patient should be positioned: a. prone b. upright c. right lateral d. dorsal recumbent with hyperextension of the neck
C
the nurse is documenting administration of a med that is given at 10 am, 2 pm, 6 pm. the med that the nurse is documenting is: a. morphine sulfate 10 mg q4h prn b. inderal 10 mg po bid c. diazepam 5 mg po tid d. keflex 500 mg po q8h
C
the nurse recognizes that an example of a schedule II med is: a. herion b. diazepam c. morphine d. acetaminophen
C
the patient is ordered to have eyedrops administered daily in both eyes. eyedrops should be instilled on the: a. cornea b. outer canthus c. lower conjunctival sac d. opening of the lacrimal duct
C
the patient is to be given the medication that is enclosed in a cylindrical gelatin coating. the nurse knows that this medication comes in the form of a : a. tablet b. powder c. capsule d. suppository
C
a patient is nauseated, has been vomiting for several hours and needs to receive an antiemetic medication. the nurse recognizes that administration of the medication, considering the patient's status and the medication, is the best via which route? select all that apply a. oral b. enteral c. parenteral d. inhalation e. topical-rectal suppository f. topical-nasal application
C, E
The nurse is to apply transdermal patches to his patients. Which of the following techniques is/are correct? Select all that apply. A. Use the same location for the new transdermal patch. B. Place transdermal patches over bony areas C. Write initials, date, and time on patches before applied D. Massage the patch when it is in place E. Remove patches if the patient requires defibrillation. F. Clean the skin site where the patch will be placed.
C, E, F
identify the factors that will promote bowel elimination. select all that apply a. lack of privacy b. immobility c. squatting d. calcium supplements e. anesthesia f. emotional stress
C,F
A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. I will use bubble bath when bathing c. I will wait to wear my tight jeans until after my urine is clear d. I will wipe from front to back after voiding
D
A health care provider may suspect that a patient is experiencing urinary retention when the patient has: A. Large amounts of voided cloudy urine. B. Pain in the suprapubic region. C. Spasms and difficulty during urination. D. Small amounts of urine voided two to three times per hour.
D
A patient is experiencing acute renal failure. What is the most common cause of this critical illness? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction
D
A patient is scheduled for an upper GI series. Which information is most important to obtain from him before the procedure? a. Allergy to lasix b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing
D
A postoperative patient is receiving morphine sulfate via PCA. The nurse assesses that the patient's respirations are depressed. The effects of the morphine sulfate can be classified as: A. Allergic. B. Idiosyncratic. C. Therapeutic. D. Toxic.
D
A test performed to visualize inflamed tissue, ulcers, and abnormal growths in the anus, rectum, and colon is a(n): A. Ileostomy. B. Paralytic ileus. C. Lavage. D. Colonoscopy.
D
A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding: A. In bathrooms other than their own. B. In a urinal. C. While lying in bed. D. In the presence of a person other than their parents.
D
An assessment is completed by the nurse and a nursing diagnosis for the oriented adult female client is identified as "Stress incontinence related to decreased pelvic muscle tone". An appropriate nursing intervention based on this diagnosis is to: A) Apply adult diapers B) Catheterize the client C) Initiate a bladder emptying program D) Teach Kegel exercises
D
At a community health fair the nurse informs the residents that the pneumococcal vaccine is recommended for patients: A. Only older than age 65 B. 40 to 60 years of age C. In any age-group who are experiencing flu-like symptoms D. of any age who have chronic lung disease
D
Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. The patient will return to previous elimination pattern. b. The patient will increase intake of grains, rice, and cereals. c. The patient will discontinue antibiotic use and contact the health care provider. d. The patient will increase fluid intake.
D
The appropriate amount of fluid to prepare for an enema to be given to an average size adult is: a. 250 to 350 ml b. 300 to 500 ml c. 500 to 750 ml d. 750 to 1000 ml
D
The client has chest tubes in place following thoracic surgery. In working with a client who has a chest tube, the nurse should: A. Clamp the tubes except during client assessments B. Remove the tubing from the connection to check for adequate suction power C. Milk or strip the tubes every 15 to 30 minutes to maintain drainage D. keep the drainage collection device upright
D
The client is admitted to the medical center with a diagnosis of right-sided heart failure. In assessment of this client, the nurse expects to find: A. Dyspnea B. Confusion C. Dizziness D. Peripheral edema
D
The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum
D
The nurse is checking the client's overall oxygenation. In assessment of the presence of central cyanosis, the nurse will inspect the client's: A. Palms and soles of the feet B. Nail beds C. Earlobes D. Tongue
D
The nurse is visiting the patient who has a nursing diagnosis of Alteration in urinary elimination, retention. On assessment, the nurse anticipates that this patient will exhibit: a. a loss of the urge to void b. severe flank pain and hematuria c. pain and burning on urination d. a feeling of pressure and voiding of small amounts
D
The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing
D
The nurse recognizes that changes in elimination occur with the aging process. An expected change in bowel elimination is which of the following? a. Absorptive processes are increased in the intestinal mucosa. b. Esophageal emptying time is increased. c. Changes in nerve innervation and sensation cause diarrhea. d. Mastication processes are less efficient.
D
The nurse recognizes that postrenal failure is associated with: a. renal damage b. low cardiac output c. vascular collapse d. functional obstruction
D
The nurse understands that medication absorption is affected by the administration route. Which route for medications has the fastest absorption rate? a. Cream applied to the skin b. Enteric-coated capsules c. Subcutaneous injection d. Intravenous injection
D
The patient has a suprapubic catheter in place. Which of the following is correct for this type of catheterization? a. irrigation is required for urine to drain b. the catheter is secured with adhesive tape c. lotions or creams are used around the site to protect the skin d. it is usually placed 4 to 5 cm above the symphysis pubis
D
The patient has an indwelling catheter. The nurse should obtain a sterile urine specimen by: a. disconnecting the catheter from the drainage tubing b. inserting a needle into the catheter tubing c. opening the drainage bag and removing urine d. using a syringe to withdraw urine from the catheter port
D
The patient is ordered an ultrasound to determine the size, shape, and location of the kidneys. The nurse knows that prior to the test the patient will a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.
D
The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? a. apply sterile gloves for the procedure b. restrict fluids before the specimen collection c. place the specimen in a clean urinalysis container d. collect the specimen after the initial stream of urine has passed
D
What action should the nurse take immediately after instilling the prescribed eyedrops into the patient's eye? a. Apply a sterile eye patch to each eye receiving drops. b. Maintain light pressure on the lower eyelid to keep it pulled down. c. Wipe the eyelid toward the inner canthus area. d. Press gently on the inner canthus area.
D
What symptom is most likely to be exhibited by the patient who complains of voiding small amounts of urine in relation to his fluid intake? a. Nocturia b. Polyuria c. Anuria d. Oliguria
D
What symptom is most likely to be exhibited by the patient who complains of voiding small amounts of urine in relation to his fluid intakes? a. nocturia b. polyuria c. anuria d. oliguria
D
When a person takes a breath in, what is the primary muscle of respiration? a. The intercostal muscles b. The neck muscles c. Muscles of the shoulder girdle d. The diaphragm
D
Which of the following artificial airways would the nurse anticipate to have a cuff at the end? a. Nasotracheal airway b. Pharyngeal airway c. Oral pharyngeal airway d. An endotracheal tube
D
Which of the following conditions would be associated with a wheezing sound on inspiration in a patient's lower posterior chest? a. Myocardial infarction b. Congestive heart failure c. Pulmonary edema d. Asthma
D
Which of the following patients may need a pharyngeal airway? a. A patient who is alert and oriented b. A patient who has a tracheostomy c. A patient with a broken nose d. A patient with decreased level of consciousness
D
Which oxygen delivery setting places a patient in danger of not receiving adequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a rate of 5 L/min c. Simple mask at a flow rate of 5 L/min d. Non-rebreather mask at a flow rate of 5 L/min
D
Which position is the priority for a patient experiencing acute shortness of breath? a. Supine position b. Reverse Trendelenburg position c. Face-down position d. Upright position
D
While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, and the stoma is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy
D
You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with: A. Absorption. B. Biotransformation. C. Distribution. D. Excretion.
D
a patient has recently had a mitral valve replacement. to prevent excess serosanguinous fluid accumulating, the nurse anticipates that care will include: a. increased oxygen therapy b. frequent chest physiotherapy c. incentive spirometry on a regular basis d. chest tube placement in the thoracic cavity
D
for the patient with diarrhea, the nurse recommends: a. fresh veggies b. milk products c. cold sodas d. mashed potatoes
D
the nurse administers the IM med of iron by the Z-track method. the med was administered by this method to: a. provide faster absorption of the med b. reduce discomfort from the needle c. provide more even absorption of the drug d. prevent the drug from irritating sensitive tissue
D
the nurse is evaluating the integrity of the ventrogluteal injection site. the nurse finds that the site by locating the: a. middle third of the lateral thigh b. anterior aspect of the upper thigh c. acromion process and axilla d. greater trochanter, anterior iliac spine, and the iliac crest
D
the patient is to receive heparin by injection. the nurse prepares to inject this med in the patient's: a. scapular region b. vastus lateralis c. posterior gluteal d. abdomen
D
the patient tells the nurse that he is experiencing nausea, vomiting, clumsiness, and blurred vision. he says that he has been taking a lot of vitamins. on the basis of the patient's symptoms, which vitamin does the nurse suspect is creating the adverse effects a. vitamin b3 b. vitamin c c. folic acid d. vitamin a
D
the physician orders 100 mg of a hypnotic med to help the patient sleep. the label on the med bottle reads Seconal 50 mg. how many tablets should the nurse give the patient a. 1/2 b. 1 c. 1 1/2 d. 2
D
the student nurse reads the order to give a 10 month old patient an IM injection. the appropriate and preferred muscle to select for a child is the: a. deltoid b. dorsogluetal c. ventrogluteal d. vastus lateralis
D
the unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning? A. Placing the client in a supine position B. Preparing for a clean or nonsterile technique C. Suctioning the oropharyngeal area first, then the nasotracheal area D. Applying intermittent suction for 10 seconds during catheter removal
D
Indicate the expected findings from the physical assessment of the urinary system. Select all that apply. a. distention over the suprapubic area b. bruit heard over the left renal artery c. discomfort on percussion of the kidney d. soft abdomen e. bilateral ecchymosis to the lower abdominal quadrants f. absence of indentation and scarring
D,F
T/F: an IM injection is to be given into the ventrogluteal muscle. the nurse should aspirate before administering the medication
False
oil retention enema
Lubricate the rectum and colon. feces absorbs the oil and become softer and easier to pass.
can changing the new ostomy pouch or complications with ostomy be delegated to UAP?
NO rationale: changing the pouch of an established ostomy may be delegated without a nurse's assistance
cleansing isotonic enema
Work by expanding the colon, thus promoting peristalsis between 750-1000mL of fluid are used
cleansing hypertonic enema
Work by osmotic pressure, drawing fluid out of interstitial spaces into the colon, which then fills with fluids and distends between 750-1000mL of fluid are used
A 63-year-old woman who has symptoms of insulin shock comes to the medical office. Which of the following is most appropriately given to the patient to reverse her insulin shock? a. Glucagon b. Insulin c. Milk d. Candy e. Gatorade
a
The most appropriate site for administration of the rabies vaccine is the a. deltoid muscle. b. gluteus medius. c. abdomen. d. thighs.
a
The most commonly used system of measurement is the a. metric system. b. apothecaries' system. c. household system. d. dram system. e. conversion system.
a
Which of the following is a drug combined with a volatile alcoholic solution? a. Spirit b. Tincture c. Elixir d. Emulsion e. Syrup
a
Which of the following routes of administration allows for the quickest absorption of medication? a. Inhalation b. Transdermal patch c. Intramuscular d. Intradermal
a
Identify the angle of insertion that is being administered: a. IM b. SUBQ c. ID
a. 90 degree b. 45 degree c. 15 degree
severe, unintended, unwanted, and often unpredictable drug reaction
adverse effect
Intake includes:
all food and oral fluids as well as tube feedings and intravenous fluids
unpredictable immune responses to medications
allergic reaction
Severe allergic reaction
anaphylactic reaction
occurs when the drug effect is decreased by taking the drug with another substance
antagonism
output of 50-100 mL in 24 hours
anuria
a reaction of airways to stimulation by irritants, allergens, pollutants, or cold air through constriction and spasms
asthma
Collapse of lung tissue in the distal part of lung
atelectasis
A drug dissolved in a solution of sugar and water is called a a. spirit. b. syrup. c. capsule. d. tincture.
b
Epinephrine and allergy treatments are often administered a. intramuscularly. b. subcutaneously. c. intradermally. d. via the Z-track method. e. None of the above are true.
b
When performing a purified protein derivative (PPD) tuberculin test, which of the following is the correct angle for needle insertion? a. 5 degrees b. 15 degrees c. 30 degrees d. 45 degrees
b
Which of the following is an example of an inscription? a. Rx b. Valium 10 mg tabs c. #30 d. I qd
b
Which of the following is the preferred site of injection for children under 3? a. Deltoid b. Vastus lateralis c. Gluteus medius d. None of the above
b
Output is measured:
by collecting it in bed pans, urinals, urinary catheters, drains, ostomy bags, nasogastric tubes, or collection devices commonly referred to as urine "hats" placed in the front of a toilet or bedside commode.
Antibiotics and viscous medications are administered to which of the following muscles? a. Deltoid b. Vastus lateralis c. Gluteus medius d. None of the above
c
How far above the rectal sphincter muscle must a suppository be inserted? a. 1/2 inch b. 1 inch c. 2 inches d. 3 inches e. 4 inches
c
The hollow part of the needle is called the a. bevel. b. point. c. lumen. d. hub. e. hilt.
c
Which of the following is a parenteral method of drug administration? a. Sublingual b. Inhalation c. Intradermal d. Buccal
c
an inflammation of the larger airways, increased production of mucous and chronic cough
chronic bronchitis
What are the four things that you should assess in urine?
color clarity odor amount
For a medication to be maintained at the proper blood level, it must be given a. in the right dose. b. in the right place. c. by the right route. d. at the right time.
d
Which of the following drug routes is a method of applying a drug to unbroken skin? a. Sublingual b. Buccal c. Parenteral d. Transdermal e. Inhalation
d
Which of the following is an advantage of intramuscular injections? a. IM injections cause less irritation of the skin than SC injections. b. It is easy to tell that they have been correctly administered because a wheal forms on the skin. c. One can give a greater amount of medication in an IM injection. d. Both a and c are advantages.
d
Which of the following is true of oral medication administration? a. It is expensive. b. It is more difficult to administer. c. The drug is absorbed through the mouth. d. The drug is absorbed through the lining of the stomach.
d
Which of the following methods of administration is the most appropriate for injecting medications that may be irritating to the skin? a. Intradermal b. Superficial intramuscular c. Venous or deep intramuscular d. Z-track
d
Which of the following statements about the inhalation method of drug administration is true? a. The respiratory tract absorbs medication more rapidly than any other mucous membrane. b. It is often used to administer nitroglycerin and scopolamine. c. Oxygen should be kept in every medical practice. d. Both a and c are true.
d
Which of the following types of immunity do vaccines produce? a. Passive b. Natural c. Permanent d. Artificial
d
an intramuscular administration of very thick penicillin? a. 15 b. 17 c. 19 d. 21
d
condition for which the drug should be administered? a. PRN b. Stat c. Routine d. Standing
d
the patient is placed in what position for vaginal suppository insertion:
dorsal recumbent or sims
painful urination
dysuria
Hepatitis A vaccines should be administered intramuscularly into which of the following muscles? a. Gluteus medius b. Gluteus maximus c. Vastus lateralis d. Ventrogluteal e. Deltoid
e
The gauge of needles for intradermal injections is usually between a. 16 and 17. b. 18 and 19. c. 20 and 21. d. 22 and 24. e. 25 and 26.
e
Which of the following statements about drugs given in subcutaneous injections is true? a. They must be isotonic. b. They must be nonviscous. c. They must be water soluble. d. They must be nonirritating. e. All of the above are true.
e
an enlargement of small air sacs on the distal end of terminal brochioles
emphysema
what general types of medications cannot be crushed for administration through and enteric tube?
enteric coated time-release sublingual buccal other medications with special coating
the involuntary passing of urine
enuresis
blood in urine
hematuria
unpredictable patient response to medication
idiosyncratic reaction
suprapubic catheter
indwelling catheter inserted directly in the bladder through an abdominal incision above the pubic bone that includes a collection system that allows urine to be drained into a bag; used in patients requiring long-term catheterization
occurs when the drug action is modified by the presence of a certain food or herb or another medication
medication interaction
the nurse assesses the area where an injection will be given. what assessment findings will require the need to use different site:
moles scars rashes breaks in skin
excessive urination at night
nocturia
output of 100-500 mL in 24 hours
oliguria
a constant dribbling of urine or frequency in urination
overflow incontinence
an infection of the lungs
pneumonia
excessive production and excretion of urine
polyuria
return-flow enema
provide relief from distention by stimulating peristalsis to improve passage of flatus between 100-200 mL of solution are alternately administered and drained from rectum
carminative enema
provide relief from distention by stimulating peristalsis to improve passage of flatus between 40-60 mL of fluids
What are the 6 rights of medication administration?
right dose right drug right time right route right patient right documentation
how are medications that are reconstituted in vials mixed:
rolling vials in hands (shaking the vial can create air bubbles)
predictable but unwanted and sometimes unavoidable reactions to medications
side effects
the patient is placed in what position for rectal suppositrory insertion:
sims
two types of urethral catheterization:
straight indwelling
loss of urine control during activities that increase intrabdominal pressure
stress incontinence
four types of urinary catheterization:
striaght foley triple-lumen coudè
occurs when the combined is greater than the effect of either substance if taken alone
synergistic effect
the desired result or action of a medication
therapeutic effect
result from a medication overdose or the buildup or medication in the blood due to impaired metabolism and excretion
toxic effect
T/F: epipen injections can be done through the patients clothes
true
sudden strong desire to void, followed by rapid bladder contration
urge incontience
