chp 29 Medication - ML5, P.U.
The charge nurse has just completed an inservice with a group of nursing students. One nurse student asks, "Why do I have to know how to give medications in different ways. I thought the unlicensed assistive personnel (UAP) performs those skills?" What is best response by the charge nurse?
Correct response: "Entry-level nurses will perform basic skills appropriate to the scope of practice and that includes administering medications through various routes." Explanation: The administration of medications to clients is a core nursing function that involves skillful technique and consideration of the client's development, health status, and safety. Also, the nursing process is often applicable to the skills of medication administration. Informing the new nurse that this profession may not be the one for them is not professional and does not foster respect for the person or the question raised. Professionalism is expected with each interaction with clients, family members and other health care members, including nursing students. Chapter 29: Medications, p. 820.
A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?
Correct response: Deltoid Explanation: The deltoid is the best site for this medication. Biologicals for infants and young children are administered at the vastus lateralis. The ventrogluteal site is used for depot formulations and irritating medications. The scapula is a site for an intradermal injection. Chapter 29: Medications, p. 853.
After teaching a group of nursing students about pharmacokinetics, the instructor determines that the education was successful when the students identify what process by which the medication is delivered to the target cells and tissues?
Correct response: Distribution Explanation: The process by which the medication is delivered to the target cells and tissues is called distribution. Absorption is the process by which a medication enters the bloodstream. Synergism is a drug interaction that increases the drug effect. The process of chemically changing the drug in the body is called metabolism; it takes place mainly in the liver. Chapter 29: Medications, p. 823.
A health care provider who just arrived on the unit gives a verbal order to the nurse regarding a nonemergent client situation. What is the nurse's appropriate response?
Correct response: Tactfully request the provider to input the order into the computerized provider order system. Explanation: Providers are to enter their own orders when they are physically present. It is appropriate for the nurse to tactfully request that the provider do so. The nurse should not input the order, nor refuse to implement it. Chapter 29: Medications, p. 831.
A nurse needs to administer a prescribed medication to a client using IV push. In which way is the medication being administered to the client?
Correct response: bolus administration Explanation: A bolus is a relatively large amount of medication given all at once; bolus administration sometimes is described as a drug given by IV push, or rapid intravenous administration. A continuous infusion, also called continuous drip, is instillation of a parenteral drug over several hours. It involves adding medication to a large volume of IV solution. After the medication is added, the solution is administered by gravity infusion or, more commonly, with an electronic infusion device such as a controller or pump. Chapter 29: Medications, p. 905.
A nurse is using an IV port when administering medication to a client. Which IV administration has the greatest potential to cause life-threatening changes?
Correct response: bolus administration Explanation: Because the entire dose is administered quickly, bolus administration has the greatest potential to cause life-threatening changes should a drug reaction occur. An electronic infusion device, continuous administration, and secondary administration do have the potential to cause life-threatening changes, but not to the same degree as a bolus administration, since the rate at which medication is administered is not as fast as during a bolus. Chapter 29: Medications, p. 905.
The nurse is reading an order that indicates that a drug is to be given to a client stat. How will the nurse administer the medication?
Correct response: immediately Explanation: Stat refers to immediacy of administration. Twice daily is written as "b.i.d.," hourly is written as "q.h.," and as needed is written as "p.r.n." Chapter 29: Medications, p. 832.
The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication?
Correct response: in the anterolateral aspect of the thigh Explanation: The vastus lateralis site is in the anterior aspect of the thigh, in which the nurse places the injection in the middle third of the thigh and is often used for infants. Therefore, this description is correct. The deltoid site is located in the lateral aspect of the upper arm. The dorsogluteal site is located in the gluteus maximus muscle in the buttocks. Chapter 29: Medications, p. 853.
The registered nurse (RN) supervises the LPN/LVN administering a purified protein derivative (PPD) tuberculin skin test to a client. During which step should the RN establish the need to intervene? The LPN/LVN:
Correct response: inserts the tip of the needle at a 5-degree angle with the bevel partly under the skin. Explanation: The bevel of the needle needs to be just below the skin surface and not showing because the tuberculin would not be properly administered, and some would leak to the surface. This would result in an ineffective, flat intradermal wheal instead of one that is 8 to 10 mm in diameter. The RN needs to intervene to ensure that the injection is done properly. Otherwise, the injection would have to be repeated at least 2 in away from the original site. Chapter 29: Medications, pp. 890-893.
Drugs known to cause birth defects are called:
Correct response: teratogenic. Explanation: Drugs know to cause birth defects are called teratogenic. Chapter 29: Medications, p. 827.
The nurse is administering a client's scheduled intramuscular injection. What is the nurse's most appropriate action?
The nurse should support the ventrogluteal site with the nondominant hand and wear gloves during in an intramuscular injection. Gloves should be worn, and a 90-degree insertion is preferred. Chapter 29: Medications, Skill 29-7 Administering an Intramuscular Injection, p. 903.
The nurse is teaching a nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct?
Correct response: "Antineoplastic drugs can be absorbed through the skin." Explanation: Antineoplastic drugs are absorbed through the skin and should always be handled with caution. All other options are incorrect. Chapter 29: Medications, p. 837.
The nurse is caring for an older adult client who sees several different health care providers and specialists. Which question will the nurse ask?
Correct response: "Do you get all of your medications filled at the same pharmacy?" Explanation: Polypharmacy is a concern in the older adult population. The nurse will want to know if medications are filled at the same pharmacy, as this is often where pharmacists will note discrepancies in medications prescribed or duplicate orders written by different providers. The other questions posed are not helpful. Chapter 29: Medications, p. 826.
The nurse is beginning to administer oral medications to a client. The client states, "I haven't taken that pill before. Are you sure it's correct?" The nurse rechecks the CMAR/MAR and finds that the medication is scheduled to be administered. Which response is most appropriate?
Correct response: "Don't take that pill yet. I will verify that the medication was ordered by your primary care provider." Explanation: This nurse should verify the medication with the prescriber. By this action, the nurse is adhering to the five "rights" of medication administration. A nurse and client should both be aware of medications that are prescribed and why they are prescribed. A nurse should not tell a client they should take a medication just because it is listed on the CMAR/MAR, nor should the nurse tell them to take it and they will follow up later. This could be a medication error. Chapter 29: Medications, p. 838.
The nurse is caring for a client who is taking nitroglycerin. Which client statement requires immediate nursing intervention?
Correct response: "I am taking tadalafil in addition to nitroglycerin." Explanation: Clients taking nitroglycerin in any form should not take drugs or herbs for erectile dysfunction. This may cause severe hypotension due to the combined vasodilation effect. Other client statements are appropriate and do not require further nursing teaching. Chapter 29: Medications, p. 824.
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?
Correct response: "I will get the hospital's information system's phone number for you." Explanation: Passwords and logins should never be shared with anyone else, nor should a nurse use his or her own password or login information to allow another individual to access the automated medication-dispensing system. Nurse B will not log in and give the medications, but rather will provide a solution by offering contact information for information systems to Nurse A so that he or she can work through their login issue. Chapter 29: Medications, pp. 833-834.
What is the best response by the nurse when a client asks about the side effects of using nasal spray?
Correct response: "Long-term use of nasal sprays can cause rebound nasal congestion." Explanation: Saying that long-term use of nasal sprays can cause rebound nasal congestion is correct, as this usually occurs when nasal sprays are used repeatedly by clients. Long-term use of nasal sprays cannot cause difficulty in coordinating breathing; this is more applicable with inhalers than with nasal sprays. Long-term use of nasal sprays do not repair the nasal passage; instead, they damage the nasal passage. Long-term use of nasal sprays does not cause an unpleasant taste; this is more appropriate with inhalers and not nasal sprays. Chapter 29: Medications, pp. 861-862.
A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?
Correct response: "Medication stays in the chamber so you can continue to inhale it." Explanation: A spacer provides a reservoir for aerosol medication. The client can take additional breaths (after the initial breath) to continue inhaling the medication held in the reservoir. The spacer does not decrease the amount of medication received, make the medication move faster, or serve as a holding device. Chapter 29: Medications, p. 865.
A client with a complex cardiac history has been prescribed digoxin 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?
Correct response: 0.5 Explanation: 1.0 mg = 1000 mcg. 0.125 mg =125 mcg. 0.0625 mg is exactly one half of 0.125 mg. If the digoxin tablet is 0.125 mg or 125 mcg, then the nurse would administer 0.5 tablet which is 0.0625mg, or 65.5mcg. Chapter 29: Medications, p. 836.
A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?
Correct response: 1 mL Explanation: The volume of a subcutaneous injection is usually up to 1 mL. An intramuscular injection is the administration of up to 3 mL of medication into one muscle or muscle group. Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL. Chapter 29: Medications, p. 849.
The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?
Correct response: 1 mL syringe; ½-inch (1.25-cm), 26-gauge needle Explanation: For a tuberculosis screening, the nurse should choose a 1 mL syringe with a ½-inch (1.25-cm), 26-gauge needle. An insulin syringe is used for insulin administration. Chapter 29: Medications, p. 845.
The nurse is preparing to administer an allergy test intradermally. At what angle will the nurse plan to insert the needle into the client?
Correct response: 10 to 15 degrees Explanation: Intradermal injections are given at a 10- to 15-degree angle. Other answers are incorrect. Chapter 29: Medications, p. 849.
The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?
Correct response: 15-degree angle Explanation: A 15-degree angle is correct, as this allows the drug to be injected between the layers of the skin. A 45-degree angle is incorrect, as this will allow the drug to be injected beneath the skin but above the muscle. A 90-degree angle is incorrect, as this will allow the drug to be injected in the muscle. A 120-degree angle is incorrect, as this will be more suitable for intravenous injections. Chapter 29: Medications, p. 849.
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?
Correct response: 5 minutes Explanation: When ear drops are to be administered in both ears, the nurse would wait 5 minutes after giving the ear drops in the first ear before administering the ear drops into the second ear. This avoids causing the medication to run out immediately after administration. Other times are longer than are needed between ears. Chapter 29: Medications, p. 861.
The nurse is preparing to administer insulin to an obese client. At what angle will the nurse plan to insert the needle into the client?
Correct response: 90 degrees Explanation: Insulin injections are given subcutaneously to clients with obesity at a 90-degree angle. Other answers are incorrect. Chapter 29: Medications, p. 903
Which medication interaction illustrates a synergism?
Correct response: A client takes acetaminophen to help her sleep. She also takes an oxycodone for pain related to recent hip surgery, which makes her even more drowsy. Explanation: A synergistic reaction is one in which one drug increases the effect of another drug. Acetaminophen and oxycodone have a synergistic relationship. Doxycycline and calcium carbonate have an antagonistic relationship. Chapter 29: Medications, p. 826.
A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which guidelines for needle selection might they discuss?
Correct response: As the gauge number becomes larger, the size of the needle becomes smaller. Explanation: The larger the gauge, the smaller the needle. The first number on a needle package is the gauge or diameter of the needle; the second number is the length in inches. When giving an injection, the viscosity of the medication directs the choice of gauge. The size of the syringe is directed by the amount of the medication to be given. Chapter 29: Medications, p. 845.
A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?
Correct response: Avoid crushing sustained-release pellets. Explanation: When administering medications through an enteral tube for a tube-fed client, the nurse must avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption. The nurse should not add medications to the formula because some medications may interact with the components in the formula, causing it to curdle or change its consistency. Additionally, a slow infusion would alter the medication's dose and rate of absorption. The nurse should mix each medication separately, not together, with at least 15 to 30 mL of water. The nurse should use warm water when mixing powdered medications to promote dissolving the solid form. Chapter 29: Medications, p. 845.
A nurse receives orders from the physician to mix a client's insulin in a syringe with two other medications. What is the recommended guideline in this situation?
Correct response: Call the pharmacist to determine compatibility of the drugs. Explanation: Mixing three drugs is not recommended, but if it must be done, contact the pharmacist and not the physician to determine the compatibility of the drugs, the compatibility of their pH values, and the preservatives that may be present in each drug. A drug compatibility table should be available to nurses who are preparing medications. Chapter 29: Medications, pp. 845-848.
The nurse is preparing to administer two IV medications. What is the appropriate nursing action?
Correct response: Consult a current drug reference book for IV compatibility. Explanation: The nurse should consult a current drug reference book for compatibility before administering two IV medications. Other answers are incorrect. Chapter 29: Medications, p. 848.
The nurse is caring for a client who has had a cerebrovascular accident. Prior to administering oral medications, what is the nurse's appropriate action?
Correct response: Consult with a speech therapist for dysphagia. Explanation: To prevent aspiration, the nurse will not administer oral medications, but will ask the provider to consult with a speech therapist who can evaluate dysphagia and recommend safe methods of medication administration. The nurse cannot automatically convert an order for medications to a different route; this would have to be considered by the health care provider. Chapter 29: Medications, p. 84.
A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration?
Correct response: Deltoid Explanation: The deltoid and ventrogluteal sites are more appropriate for adults than the vastus lateralis. The scapula is a site for an intradermal injection. The biceps brachii muscle is not used for intramuscular injections. Chapter 29: Medications, pp. 900-904.
The nurse is assessing a client with diabetes who has poor vision. Which feature of the insulin pen makes it beneficial for this client?
Correct response: Each unit of insulin is accompanied by a clicking sound in the pen. Explanation: Each unit of insulin is accompanied by a clicking sound in the pen. This is a beneficial feature for the client who has poor vision, as the sound will alert the client to count when selecting the prescribed dose. Being easily transported, being easier to learn, and having a variety of types available are all advantages for using insulin pens, but they do speak specifically to this client. Chapter 29: Medications, p. 851.
When administering a subcutaneous injection to a client, the needle pulls out of the skin when the skin fold is released. What would be the appropriate next action of the nurse in this situation?
Correct response: Engage safety shield on needle guard and discard needle appropriately. Explanation: The needle needs to be disposed of properly after engaging the safety guard because the needle cannot be reinserted due to contamination. A new needle can be attached to the syringe and the remainder of the medication administered after cleansing the site again. The incident does warrant notifying the primary care provider. Chapter 29: Medications, pp. 851-893.
Which actions would the nurse perform when administering a subcutaneous injection correctly? Select all that apply.
Correct response: Grasp and bunch the area surrounding the injection site or spread the skin taut at the site. Inject the needle quickly at an angle of 45 to 90 degrees. After removing the needle, do not massage the area to prevent hematoma formation. Explanation: The decision to create a skin fold is based on the nurse's assessment of the client and needle length used. Pinching is advised for thinner clients and when a longer needle is used, to lift the adipose tissue away from underlying muscle and tissue. If the skin is pulled taut, it provides easy, less painful entry into the subcutaneous tissue. Injecting at 45 or 90 degrees depends on the amount of subcutaneous tissue at the injection site. The area should not be massaged. Massaging the site can damage underlying tissue and increase the absorption of the medication. The arm should be relaxed at the client's side in order to expose the subcutaneous tissue of the outer aspect of the upper arm. The syringe is held in the dominant hand and the cap of the needle is removed with the nondominant hand. Aspiration is not necessary for subcutaneous injections as there is little blood supply in the subcutaneous tissue. Chapter 29: Medications, p. 849.
Which situation accurately describes a recommended guideline when administering oral medications to clients?
Correct response: If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food. Explanation: Medication can be added to small amounts of food, but should not be added to liquids. If unsure whether the medication was swallowed, check the client's mouth and cheeks. If a pill is dropped, it should be discarded. If a client vomits, notify the health care provider to see if the medication should be readministered. Chapter 29: Medications, p. 878.
Which organ is the primary site for drug metabolism?
Correct response: Liver Explanation: The liver is the primary site for drug metabolism. The heart circulates blood so that the drug can reach target tissues. Lungs are responsible for respiration and no drug metabolism unless the medication is an inhalation medication. Kidneys are responsible for excretion of the medications. Chapter 29: Medications, pp. 824-924.
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Correct response: Lock the medications in a cart and finish them upon return. Explanation: Once medications have been prepared the nurse must either stay with the medications or lock them in an area such as the medication cart. The medications should never be left unattended or placed back in their containers. Another nurse cannot administer medications that have been prepared by the first nurse. Chapter 29: Medications, p. 838.
A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which responsibility does the nurse have to complete when handling narcotic medications? Select all that apply.
Correct response: Maintain an accurate account of the use of the medication. Record each medication used from the stock supply. Count each narcotic medication at the change of each shift. Explanation: When handling narcotic medications, the nurse should have an accurate account of the use of the medications and a record of each medication used from the stock supply, and the nurse should count each narcotic at the change of each shift. Narcotic medications are controlled substances, meaning that federal laws regulate their possession and administration. The nurse should not place the medication in the container with other prescribed medications or place the medication along with other medications on the nursing unit. An individual supply is placed in a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay. Chapter 29: Medications, p. 836.
Which technique should the nurse employ when instilling otic medication in an adult ear?
Correct response: Pull the client's ear up and back. Explanation: Pulling the client's ear up and back is correct, as this will straighten the auditory canal of the adult client. Tilting the client's head towards the ear in which the medication is being instilled and tilting the client's head back with face upward are incorrect, as these techniques will allow the medication to drain outside the ear. Pulling the ear down and back is incorrect, as this technique is used to straighten the auditory canal of a child, not an adult. Chapter 29: Medications, p. 861.
The nurse is teaching a client about insulin. What teaching will the nurse include? Select all that apply.
Correct response: Rapid-acting insulin and short-acting insulin are often combined with intermediate-acting insulin. Humulin 50/50 contains equal amounts of intermediate-acting and short-acting insulin. Explanation: The nurse will teach that certain types of insulins may be mixed together in a syringe just before administration. Glargine is never mixed with any other type of insulin. Rapid-acting insulin and short-acting insulin are often combined with intermediate-acting insulin. For example, Humulin 50/50 contains equal amounts of intermediate-acting and short-acting insulin. Chapter 29: Medications, p. 848.
The nurse has received a telephone order for a client from a health care provider. How will the nurse indicate in the documentation that the order was received via telephone?
Correct response: Record "T.O." at the end of the order. Explanation: Recording "T.O." at the end of the order indicates that this was a telephone order. Another nurse should not cosign the order. Reminding the provider to sign the order as soon as possible is helpful, but it does not indicate that this was a telephone order. Chapter 29: Medications, p. 842.
While administering a medication via a syringe, a client sharply moves and the nurse accidentally encounters a needlestick. What is the priority nursing action?
Correct response: Report the needlestick to the nurse manager. Explanation: Upon encountering a needlestick, the nurse's priority action is to report the injury. Other actions can take place after the injury has been reported. Chapter 29: Medications, p. 868
A nurse is preparing to administer a scheduled dose of enteric-coated ASA to a client who has a history of angina. When preparing the medication, the nurse is careful to check the five rights of medication administration. The five rights include which of the following?
Correct response: Right time Explanation: The five rights consist of the right client, right drug, right dose, right route and right time. It is prudent to be aware of the right documentation, setting and reason, but these are not considered to be among the five rights. Chapter 29: Medications, p. 838.
A nurse is assessing a client's lower arm for insertion of an IV catheter. The nurse palpates the vein and notes that it feels hard. Which action by the nurse would be most appropriate?
Correct response: Select another site. Explanation: If a vein appears hard or ropelike, the nurse should select another spot for the venipuncture. Applying a warm compress would be used to help dilate the vein. Loosening the tourniquet would have no effect on the "hardness" of the vein. The vein should not be used. Applying a topical anesthetic is appropriate to reduce the pain associated with insertion. However, a vein that feels hard should not be used. Chapter 29: Medications, p. 857.
The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order?
Correct response: Standing order Explanation: This is an example of a standing order, which is to be carried out as specified until it is cancelled by another order. STAT order is immediate and this order does not state that. Single order is documented as a one time order. "As needed" order would be p.r.n. Chapter 29: Medications, p. 831.
A client who has been receiving a secondary infusion of a new antibiotic for several minutes reports itching and a sensation of throat tightness. What is the priority nursing intervention?
Correct response: Stop the infusion of the antibiotic. Explanation: The client may be experiencing a reaction to the antibiotic. Because intravenous administration occurs quickly, life-threatening reactions can also occur quickly. The first nursing action is to stop the infusion. The nurse will proceed to assure that there is an open airway, assess the skin for rash, and activate the Rapid Response Team if needed. Chapter 29: Medications, p. 908.
A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason?
Correct response: The area is free of major blood vessels and fat. Explanation: The ventrogluteal site for intramuscular injection is free of major blood vessels and fat. It is considered the safest and least painful site. The dorsogluteal site is near the sciatic nerve and involves a high possibility of injecting into subcutaneous fat. The deltoid region for an intramuscular injection has little overlying subcutaneous fat and lies close to the radial nerve. Chapter 29: Medications, p. 853.
Regarding medication administration, what must occur at the change of shifts?
Correct response: The narcotics for the division are counted. Explanation: Health care facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine). Chapter 29: Medications, p. 839.
The nurse is preparing to administer a transdermal medication. How should this be accomplished?
Correct response: The nurse should apply the medication directly to the skin. Explanation: Transdermal medications are adsorbed through the skin. Injectable medications are either delivered intramuscularly (in the muscle) or subcutaneously (or below the dermis). By mouth medications are taken by swallowing. Medications can also be given in the vagina, rectum, eyes, and ears. Chapter 29: Medications, p. 823.
Which nursing strategy should the nurse employ to assist a child who has difficulty coordinating inspiration with the use of a handheld inhaler?
Correct response: The nurse should use a nebulizer to administer the medication. Explanation: The nurse's use of a nebulizer to administer the medication is correct, as this is an alternative to administering an inhalant for young children. Instructing the child to prolong his/her inhalation is incorrect, as this is used to reduce side effects of using inhalants. Assessing the child's mucous membranes is incorrect, as this action is used to identify any break in the continuity of the membranes and will not assist with the coordination of inspiration. Providing simple written instructions is incorrect, as this will enhance the teaching/learning process of the child and not the coordination of the child's inspiration. Chapter 29: Medications, p. 865.
To which client would the nurse be most likely to administer a p.r.n. medication?
Correct response: a client who is reporting pain near the surgical site Explanation: A report of "breakthrough" pain, especially postsurgery, would likely require the nurse to administer a p.r.n. analgesic. A new onset of chest pain would likely require a stat order, while longstanding treatment of hypertension and asthma would likely include standing orders for relevant medications. Chapter 29: Medications, pp. 831-832
What is required to manually regulate an IV drip? Select all that apply.
Correct response: a clock tubing with a roller clamp Explanation: A roller clamp adjusts the flow rate according to drops per minute counted in the drip chamber. Count the drops as they fall into the drip chamber for 15 seconds, then multiply this number by 4 to determine the rate of flow for 1 full minute. Use the roller clamp to adjust the flow rate until it corresponds with the prescribed rate of flow. Chapter 29: Medications, pp. 913-914.
The nurse is administering an intramuscular injection to a client. Which action made by the nurse could assess whether the needle is in the client's blood vessel or not?
Correct response: aspirating for a blood return Explanation: Aspirating for a blood return is correct, as this will determine if the needle is in the blood vessel. Inserting the needle at a 90-degree angle is incorrect, as this directs the needle in the muscles. Withdrawing the needle and immediately releasing the taut skin is incorrect, as this creates a diagonal path to prevent leaking in the subcutaneous layer of the tissue. Waiting 10 seconds with the needle still in place and the skin held taut is incorrect, as this provides time to distribute the medication in a larger area. Chapter 29: Medications, p. 852.
A client has an intermittent infusion device inserted for the administration of antibiotic therapy every 6 hours. The nurse would expect to flush the device at which frequency?
Correct response: before and after each medication administration Explanation: Peripheral intermittent lines are usually flushed with preservative-free 0.9% NaCl before and after each medication administration and every 8 hours when medications are not being given. Most agencies recommend changing intermittent devices every 72 hours to ensure patency and prevent common complications of IV therapy. Chapter 29: Medications, p. 821.
The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?
Correct response: intradermal Explanation: The nurse will use the intradermal route, which is injecting the drug between the layers of the skin. The subcutaneous route is reserved for drugs to be injected beneath the skin but above the muscle. The intramuscular route is reserved for drugs to be injected in the muscle. The intravenous route is reserved for drugs to be instilled into veins. Chapter 29: Medications, p. 849.
A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle?
Correct response: intradermal Explanation: When giving an intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. When the nurse administers a subcutaneous injection, the angle of entry is either 45 degrees or 90 degrees, whereas for intramuscular injections, the angle is 90 degrees. Intravenous injections are instilled into the veins of the client at an angle of around 15 degrees, but only if no venous access port is in place. Chapter 29: Medications, p. 849.
A nurse is using the Z-track technique to administer an injection to a client. Which injection route utilizes the Z-track technique?
Correct response: intramuscular Explanation: When administering intramuscular injections, nurses may administer drugs that may be irritating to the upper levels of tissue by the Z-track technique. Clients report slightly less pain during (and the day after) a Z-track injection compared with the usual intramuscular injection technique. The Z-track technique is not suitable for intravenous injections, as they are administered into the veins, nor is it used for intradermal or subcutaneous injections. Chapter 29: Medications, p. 855.
The nurse is caring for a client with a yeast infection. Which medication does the nurse anticipate will be prescribed?
Correct response: miconazole Explanation: The nurse anticipates that miconazole, a vaginal cream, will be prescribed for a yeast infection. Oxymetazoline is a nasal decongestant used to alleviate congestion; bisacodyl is a rectal suppository used for softening stool; timolol is an eye drop used to treat glaucoma. Chapter 29: Medications, p. 862
When administering heparin subcutaneously, the nurse should:
Correct response: never aspirate. Explanation: When administering heparin subcutaneously, never aspirate before administration. Chapter 29: Medications, p. 925.
A nurse has to administer a subcutaneous injection to a client. For which client can the nurse administer a subcutaneous injection at a 90-degree angle?
Correct response: obese client Explanation: The nurse inserts the needle at a 90-degree angle to reach the subcutaneous tissue in normal-size or obese clients who have a 2-inch (5-cm) tissue fold when it is bunched. For thin clients who have a 1-inch (2.5-cm) fold of tissue, the nurse inserts the needle at a 45-degree angle. Bunching is preferred for infants, most children, and thin adults. Chapter 29: Medications, p. 849.
Which action made by the nurse demonstrates respect for the client's dignity when administering an intradermal injection?
Correct response: pulling the curtain or closing the door Explanation: Pulling the curtain or closing the door is correct, as this provides privacy for the client. Identifying the client using at least two methods promotes safety by ensuring that the right client gets the drug. Refusing to massage the area after removing the needle is incorrect, as this could interfere with test results. Determining how much the client understands is incorrect, as this action is to provide an opportunity for health teaching. Chapter 29: Medications, p. 892.
When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug?
Correct response: swallowing the medication Explanation: When administering medication by sublingual application, the client should avoid swallowing or chewing the medication. Eating or smoking during administration is also contraindicated. Taking the medication on an empty stomach, talking, or performing physical activities may not be contraindicated when administering drugs sublingually. Chapter 29: Medications, pp. 833-845.
The chemotherapy client has been admitted for thrombocytopenia. Which blood product will the nurse anticipate administering?
Correct response: Platelets Explanation: One common indication for platelet transfusion is thrombocytopenia following chemotherapy. Chapter 29: Medications, p. 863.
A nurse needs to administer a prescribed injection to a toddler. Which injection site is most suitable for the client?
Correct response: vastus lateralis site Explanation: 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. The ventrogluteal site, however, is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children. Chapter 29: Medications, p. 853.
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