Prep U Medication and Asepsis
Dose of intradermal and degree
0.5mL, 5-15 degree
Intradermal Injection needle size and gauge size
1/4" to 1/2" needle, 25 to 27 guage
A nurse is preparing to administer a rectal suppository to an adult client. How many inches (centimeters) should the nurse plan to insert the suppository?
3 in (7.5cm)
Subcutaneous Injection needle and gauge
3/8" to 1" needle, 25 to 30 gauge
The does for intramuscular injection and the degree
4mL for adults, 72 to 90 degrees
Intramuscular Injection needle and gauge size
5/8" to 1 1/2" needle, 20 to 25 gauge
A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? a. "All visitors who enter the room must wear N95/surgical masks." b. "Under no circumstances should you touch the client." c. "No visitors are allowed in the room to decrease the spread of disease." d. "Everyone who enters the room must wear a gown and glo
a
The nurse has completed administering medications through an enteral tube used for decompression. What is the appropriate nursing action? a. Clamp the tube for at least 30 minutes. b. Remove the enteral tube. c. Irrigate with normal saline. d. Immediately administer tube feeding.
a
The nurse has given medications to four clients. Which client will the nurse monitor most closely for a possible reaction to occur? a. client with infection who received a bolus of Lactated Ringer's solution b. client with allergies who received diphenhydramine by mouth c. client with congestion who received a nasal corticosteroid d. client with headache who received ketorolac intramuscularly for headache
a
The nurse is caring for an older adult with influenza. Which precautions will the nurse begin? a. droplet b. none c. contact d. airborne
a
When does a nurse first perform the three checks of medical administration
as the nurse reaches for the drug package or container
A nurse needs to administer a continuous medication drip to a client. The nurse knows that, for a continuous infusion, she will likely need to add medication to which volume of IV solution? a. 150 to 250 mL b. 500 to 1,000 mL c. 15 to 50 mL d. 50 to 100 mL
b
A team of nurses is caring for a client with tuberculosis. They have not been fitted for N95 respirators. How will the team proceed with care? a. refrain from providing care until a nurse who has been fitted arrives b. utilize a powered air purifying respirator (PAPR) c. enter the room as normal but maintain a 3-foot (1-meter) distance from the client d. use a regular mask and continue to provide care as usual
b
An order was made for a client who is cognitively impaired to have a nitroglycerin transdermal patch. On which area of the body is the nurse expected to place the patch? a. lower back b. upper back c. upper chest d. lower chest
b
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? a. 15 minutes b. 5 minutes c. 20 minutes d. 10 minutes
b
The nurse is caring for an older adult with streptococcal pneumonia. Which precautions will the nurse begin? a.none b.droplet c.airborne d.contact
b
When providing care to a incontinent client with a history of methicillin-resistant Staphylococcus aureus (MRSA), what is the priority goal for the nurse's observable(wearing a gown) intervention? a. Maintaining the cleanliness of the nurse's uniform b.Avoiding the introduction of microorganisms to the nurse's uniform c. Preventing the introduction of microorganisms to the client d. Providing a clean environment while providing client care
b
Which client would the nurse consider the most infectious? a. A client who is in the convalescent period b. A client who is in the prodromal stage c. A client who is in the incubation period d. A client who is in the full stage of illness
b
A nurse is caring for a client with ringworm. Which microorganism causes ringworm in a client? a. Rickettsiae b. Protozoans c. Fungi d. Helminths
c
The client has a prescription for 1000 mL of normal saline IV over 4 hours and following that an additional 1000 mL IV over 8 hours. Which are the correct drip rates with a drop factor of 20 drops per milliliter? a. 84 drops/min followed by 41 drops/min b. 83 drops/min followed by 41 drops/min c. 83 drops/min followed by 42 drops/min d. 84 drops/min followed 42 drops/min
c
The nurse is preparing to administer meperidine as an intramuscular injection in an adult client's deltoid site. Which needle should the nurse select for this injection? a. 5/8-inch; 24-gauge b. 1½-inch; 18-gauge c. 1-inch; 22-gauge d. 2-inch; 18-gauge
c
A client on a surgical unit has developed an infection at the site of a diagnostic laparoscopy. This type of infection is best termed as: a. exogenous. b. endogenous. c. antibiotic resistant. d. iatrogenic.
d
A nurse is applying a nitroglycerine transdermal patch to a client. What is the preferred site to use? a. Lower leg b. Any hairless surface c. Bicep d. Chest
d
A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which action should the nurse perform to ensure that all the medication is equally distributed when withdrawing? a. Tap the barrel of the syringe near the hub. b. Use a smaller-gauge needle to withdraw the medication. c. Insert the filter needle completely in the ampule. d. Tap the top of the ampule before withdrawing the medicine.
d
The charge nurse on the medical/surgical unit is reviewing physician orders for a client with a diagnosis of congestive heart failure. Which infusion orders would the nurse question? a. 50 mL D5W to run in 60 minutes b. 20 mL 0.9 NaCl to run in 20 minutes c. 250 mL 0.9 NaCl to run in 60 minutes d. 1000 D5W to run in 30 minutes
d
The nurse is discussing epidural analgesia with the nursing student. Which of statement by the nursing student indicates a need for additional education? a. "The epidural is always discontinued after the birth of the newborn." b. "The client may be able to control the epidural analgesia infusion." c. "The epidural analgesia may be used in the laboring client." d. "Epidural analgesia is always administered in a continuous infusion to prevent or treat pain."
d
The nurse is initiating isolation precautions for a client who has chronic Clostridium difficile infection. What should the nurse be sure to include with these precautions? a. recognize that this type of infection requires droplet precautions b. include a N95 respirator mask for health care staff entering the room c. remind others to use a mask when caring for this client d. be sure that there are gloves of various sizes and gowns for use
d
The nurse is reviewing the plan of care for assigned clients. Which client has the highest risk for developing an infection? a. a middle-aged adult who takes prescribed medication to control blood pressure b. an adolescent who has a right radial fracture c. a school-age child who is current with immunizations d. an older adult client with a history of heart failure
d
Which nursing action best exemplifies proper drug-diversion prevention of client medications? a. The nurse manager logs into the automated medication-dispensing system for all nurses. b. The nurse logs out of the automated medication-dispensing system after each client visit. c. The nurse has an information technology employee access the automated medication-dispensing system after maximum dose has been administered. d. The nurse does not share the personal automated medication-dispensing system password.
d
Ampule
glass flask containing a single dose of medication for parenteral administration
A client is being started on total parenteral nutrition (TPN). When initiating the therapy, the nurse gradually tapers up the infusion rate as ordered to prevent which potential complication?
hyperglycemia: body does not produce enough insulin
subcutaneous injection
injection into the subcutaneous tissue that lies between the epidermis and the muscle
subcutaneous injection dose and degree
less the 1 mL, 45 to 90 degree angle
How to inject a subcutaneous injection
pinch or stretch skin
piggyback delivery systems
require the intermittent or additive solution to be placed higher than the primary solution container
Why use z track for intramuscular
used to prevent tracking (leakage) of the medication into the subcutaneous tissue (underneath the skin). During the procedure, skin and tissue are pulled and held firmly while a long needle is inserted into the muscle.