271 PrepUs - Week 7
Pull the client's ear up and back (This will straighten the auditory canal of the adult client)
Which technique should the nurse employ when instilling otic medication in an adult ear?
1 mL
A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?
Sublingually
Administration under the tongue
Place the date on the vial and retain for future use.
In preparing to administer a drug to a client, the nurse has pierced a multi-use vial of medication. What is the appropriate nursing action?
If a child refuses to take medication, crush the medication, if allowable, and add to a small amount of food. (Medication can be added to small amounts of food, but should not be added to liquids.)
What situation accurately describes a recommended guideline when administering oral medications to clients?
PRN (As needed)
What type of prescription would the health care provider most likely write to treat a client whose pain levels vary widely throughout the day?
The Shaft of a needle
Refers to the length of the needle
Lumen of needle
Refers to the opening of the needle
Bevel of a needle
Refers to the slanted portion of the needle that provides access into the vein. This, should always be facing up when inserted into the skin
The opioids for the division are counted. (Health care facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine).)
Regarding medication administration, what must occur at the change of shifts?
"I must wait at least 1 full minute between inhalers." (The canisters must be shaken after being placed in the holder. After breathing the medication in over 10 seconds, the client should exhale slowly through pursed lips. Holders should be rinsed in warm water daily and cleaned weekly with mild soap and water.)
The nurse is teaching a client about using two inhalers. Which client statement reflects that nursing teaching has been effective?
"I take my child's anxiety medication occasionally, when I get very anxious about something." (The client should be immediately counseled to never take another person's medication and why.)
The nurse is teaching an older adult client with rheumatoid arthritis about taking medications at home. Which client statement does the nurse determine is unsafe and requires further nursing intervention?
"Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."
The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?
Antineoplastic drug absorption
These drugs can be chemotherapeutic medications and can be absorbed through the skin, and should always be handled with caution.
Metered-dose inhaler for asthmatic patient
This is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed.
Ampoule
This is a sealed glass or plastic bulb containing solutions for hypodermic injection (the glass drug containers must be broken to withdraw the medication)
Lipoatrophy
This is defined as the localized loss of fat tissue
Pharmacokinetics
This is defined as the process by which a drug moves through the body and is eventually eliminated.
Buccal medication administration
This med admin is described as placing a medication underneath the upper lip or in the side of the mouth
Lipohypertrophy
This, is a lump under the skin caused by accumulation of extra fat at the site of many subcutaneous injections of insulin.
Gauge of a needle
This, refers to diameter of needle, as the diameter increases this, decreases.
Tactfully request the provider to input the order into the computerized provider order system. (Providers are to enter their own orders when they are physically present. The nurse should not input the order, nor refuse to implement it.)
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?
Document administration of the medication immediately after administering the drug.
A nurse educator is reviewing information related to medication administration documentation with a group of graduate nurses. Which guideline for documenting will the nurse discuss with the group?
The Deltoid is the best site for this medication. Biologicals for infants and young children are administered at the vastus lateralis.
A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?
Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis. (Sites commonly used for an intradermal injection are the inner surface of the forearm and the upper back, under the scapula. Various sites may be used for subcutaneous injections, including the outer aspect of the upper arm, the abdomen (from below the costal margin to the iliac crests), the anterior aspects of the thigh, and the upper back. Subcutaneous injections are administered at a 45- to 90-degree angle, based on the amount of subcutaneous tissue present and the length of the needle. Pinching is advised for thinner clients and when a longer needle is used, to lift the adipose tissue away from underlying muscle and tissue.)
A nurse is administering enoxaparin sodium (anticoagulant) to a client with deep vein thrombosis, via the subcutaneous route. What is a recommended guideline when administering a subcutaneous injection?
When the client has disorders (ex. severe burns) that affect the absorption of medications (IV therapy is also used in an emergency when a quick response is needed.)
A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which situation?
-Place the extremity in a dependent position for several seconds, gently tap your finger over the vein, rub or stroke the skin upward toward the tourniquet, or have the client open and close his fist several times. -If the client's skin is cold, warm it by rubbing and stroking the arm -Cover the entire arm with warm compresses for 5 to 10 minutes to help distend the veins.
A nurse is preparing to insert an IV device in an older adult. The nurse is able to palpate the vein but is having difficulty getting it to dilate. Which action would be most helpful for the nurse to do?
"Lipoatrophy and lipohypertrophy are conditions of the fatty tissue that can occur from not rotating injection sites."
A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which statement best describes lipoatrophy and lipohypertrophy to the client?
Larger diameter
A nurse is using an 18-gauge needle to administer medication to a client. The nurse knows that, when compared with a 27-gauge needle, an 18-gauge needle has which feature?
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.
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Assess the IV site for redness. (If tenderness, fever without obvious source, or symptoms of local or bloodstream infection are present, remove the dressing and inspect the site directly.)
A young woman has an IV infusing for magnesium sulfate to treat preterm labor. The woman develops a fever. What is the first assessment the nurse should make?
Never aspirate before administration
When administering heparin subcutaneously, the nurse should:
Set the antihypertensive dose aside pending assessment.
The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this upcoming dose of scheduled unit-dose packaged antihypertensive medication?
Stay with the client while medications are taken. (The nurse must wait with the client to personally acknowledge that medications have been taken (or refused).)
The nurse has confirmed the client's identity and provided a client with oral medications to take. What is the next appropriate nursing intervention?
Waste the medication with another nurse witness present. (If a controlled substance is wasted, this waste must be witnessed by and documented by the wasting nurse and another nurse.)
The nurse has drawn opioid pain medication into a syringe. When preparing to administer the medication, the client refuses, stating that pain is controlled currently at a level of 2 on a scale of 1 to 10. Which action should the nurse take to waste the medication?
Record "T.O." at the end of the order.
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?
The injection site should be cleansed with alcohol in a circular motion from the injection site outward.
The nurse is administering a subcutaneous injection of insulin to a client. Which action would the nurse take after choosing the appropriate administration site?
Swallowing the medication
When instructing a client regarding sublingual application, the nurse should inform the client that which action is contraindicated when administering the drug?
Contact the health care provider to clarify the prescription by reading back to the provider, update the electronic medical record (EMR) while on the phone, then document it was a phone prescription. (Always have the health care provider clarify the prescription. The nurse cannot assume that a medication is to be given at certain times, nor should another nurse verify the frequency or clarify the prescription. The nurse should remain on the phone with the provider and read back the entire prescription for verification. Documentation should reflect that it is a phone prescription. Usually the phone prescription has to be reviewed and cosigned by the provider within 24 hours.)
The nurse is caring for a client with a secondary urinary tract infection for which amoxicillin 250 mg PO has been prescribed. The nurse recognizes this as a drug that is routinely administered every 8 hours; however, the prescription does not state the frequency of administration. The health care provider is no longer present. What is the appropriate nursing action?
"I will eat a meal within a half hour of taking my morning insulin."
The nurse is caring for a client with diabetes. Which client statement reflects that nursing teaching has been effective?
83 drops/minute
The nurse is infusing 0.9% NS to a hypovolemic client s/p an MVA. The nurse is ordered to infuse 1,000 mL of fluid over 1 hour. The tube has a drop factor of 5 drops/ml. What is the drip rate of the infusion?
33 drops/minute
The nurse is infusing ampicillin IV for Mr. B. The medication is diluted in 100 mL of NS and is to infuse over 1 hour. The nurse has tubing with a drop factor of 20 drops/ml. What is the drip rate of this infusion?
Administer the medication as prescribed (It is not necessary to discard the syringe or medication and start over. A new plunger is not needed since the contaminated plunger will enter the barrel of the syringe when pushing the medication out and will not come into contact with the medication. Therefore, it will not contaminate the medication.)
The nurse is preparing a medication from a vial and contaminates the plunger after the medication is drawn into the syringe. What should the nurse do next?
In the anterolateral aspect of the thigh (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. The deltoid site is located in the lateral aspect of the upper arm.)
The nurse is preparing to administer an IM injection in the vastus lateralis site. Where will the nurse administer the medication?
Inner surface of the forearm (Sites commonly used for intradermal injections are the inner surface of the forearm and the upper back, under the scapula.)
The nurse is preparing to administer an allergy test via an intradermal injection. Which injection site would be most appropriate in this situation?
Insert a new IV medication lock and remove the old one. (The nurse is to flush the medication IV lock every 8 to 12 hours, or depending on the facility policy. When flushing the IV lock, the nurse verifies the patency of the lock by aspirating blood return and the lock should flush without resistance. If the nurse is unable to flush without resistance, if there is leaking from the site during flushing, or if patency cannot be verified, the nurse should remove the IV lock and insert a new IV lock.)
The nurse is preparing to administer prescribed intravenous antibiotics to a client. While assessing the medication lock, the nurse notes that there is resistance when administering the saline flush solution. What would be the best action by the nurse?
"Long-term use of nasal sprays can cause rebound nasal congestion."
What is the best response by the nurse when a client asks about the side effects of using nasal spray?
a 58-year-old woman with stage 3 breast cancer requiring weekly chemotherapy (A central port is easily accessed for chemotherapy sessions, then the access is discontinued even though the port remains in place subcutaneously. A central port also allows for the infusion of chemotherapy into a central vessel; this is important because chemotherapy is caustic and severely damages peripheral vessels.)
What kind of client would most likely require placement of an implantable port?
