240 exam III
A nurse pays a house visit to a client who is on parenteral nutrition (PN). The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse?
"Tell me more about how it feels to eat with your family."
A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?
"The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position."
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?
0.5
A patient drinks 8 oz of water. Which of the following is a correct conversion of the patient's intake?
240 ml
medication time limit
30 min before 30 min after
Which of the following patients is exhibiting drug tolerance?
A patient requires an increased dose of a medication to achieve therapeutic effect
The nurse has entered a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first implement in this interaction?
A yes/no question
Which of the following demonstrates the correct use of one of the six rights of medication administration?
Administering a patient's medication by the route the provider has prescribed
What governing body put out papers to serve as guidelines for all nurses
American Nurse Association CODE OF ETHICS- delineates our conducts and responsibilities
Which of the following represents the correct administration of the prescribed medication?
Amoxicillin 1 gram PO prescribed; two 500 mg tablets given
An uncommon, unexpected, or individual drug response thought to result from a genetic predisposition is called
An idiosyncratic effect
A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which action should the nurse perform when administering oral medication to the client?
Avoid administering medication prepared by another nurse
You have a handwritten medication order that is difficult to read. Which of the following is the most appropriate action to take to avoid an error in medication administration?
Call the medical provider for the clarification of the order
According to the nurse practice act, the nurse is liable for
Clarifying a physician order
During an assessment of a newly admitted client the nurse asks the client many questions. The nurse begins the assessment by asking, "How many times have you been hospitalized this year for your back pain?" This is an example of which type of question?
Closed question
You are reading the physician's order and note date and time of the prescriptions, as well as the physician's signature. Which of the following completes the prescription?
Digoxin 1.25 mg PO daily
Which of the following statements accurately describes the relationship between therapeutic communication and the nursing process? Select all that apply.
Effective communication techniques, as well as observational skills, are used extensively during the assessment step. Correct! Verbal and nonverbal communication are used to educate, counsel, and support clients and their families during the implementation phase. Correct! Nurses rely on the verbal and nonverbal cues they receive from their clients to evaluate whether client objectives have been achieved.
A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration?
Ensures that the right medication is given at the right time by the right route
Which of the following are examples of a nurse using nontherapeutic communication techniques? Select all that apply
Giving advice Correct! Focusing on the nurse rather than the client Correct! Making value judgments Correct!
Which of the following is an example of closed-ended questioning? (Select all that apply)
How long have you been depressed? Do you want to take your medication? Correct! Are you going to therapy tomorrow?
Which of the following is your highest priority action for ensuring overall safety during medication administration?
Identify the patient by two acceptable methods
A nurse is caring for a client who states, "I would like to go out on a date with you." Which of the following is an appropriate response by the nurse?
Inform the client that this is an inappropriate statement
With which route of drug administration are there no barriers to absorption?
Intravenous
When educating an older adult client about the administration of medication during discharge, the nurse notes that the client is having difficulty comprehending the instruction. What intervention should the nurse follow in this case to ensure the client's safety?
Involve a second responsible person in the instruction
A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. What is a feature of a metered-dose inhaler?
It is a canister that contains pressurized medication.
Which actions are included in the required "checks" for safe medication administration? Select all that apply
Read the medication label after retrieving the medication from the drawer. Correct! Read the medication label just before administering a unit dose medication to the client. Correct!
You are giving a patient several PO medications. The patient tells you she can only take one pill at a time. it is appropriate to
Remain at the bedside until you are sure the patient has taken all of the medications
Which guideline should a nurse use when choosing a position (location) in relation to a client during a verbal interaction?
Take note of the client's cues when choosing a position and act on these cues
When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?
The client's tone of voice
In order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?
Therapeutic communication
A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following responses is appropriate?
This must be a difficult time for you
To which client would the nurse be most likely to administer a prn medication?
a client who is reporting pain near the surgical site
what do I need for a prescription to be right
date, time, route, patient, dose, medication, signature,
patient refuses
document in medical record with refusal
Confidentiality
ethical and legal responsibility protected by HIPAA
fidelity
keeping promises and commitments made to others
Altruism
only doing something for the greater good, you get nothing out of it
justice
process that distributes benefits, risk, and costs fairly
Advocacy
protection and support of another person rights
A drug's generic name is the
same as its nonproprietary name
autonomy
support personal decision making, ensure clients are involved in care, honor clients right to self determination
Veracity
telling the truth
A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets?
to prevent gastric irritation
autogenic training
uses autosuggestion to reprogram the mind to override stresses and calm the body
how do you make sure you have the right patient
using 2 identifiers (state your name and dob)
A client presents at a community shelter after surviving the destruction of her home by a fire. Which of the following questions should the nurse ask to determine the client's ability to cope?
who do you talk to when you have the feeling of being overwhelmed?