Chapter 29
A nurse is caring for a client with pneumonia at a health care facility. The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which component is a required component of the medication order?
Client's name
A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which instructions are stated on the label of a vial container?
amount of diluent to be added
The nurse is preparing supplies for a tuberculosis screening. The nurse should choose which syringes and needles?
1 mL syringe; ½-inch (1.25-cm), 26-gauge needle
Which technique should the nurse employ when instilling otic medication in an adult ear?
Pull the client's ear up and back.
Which action describes buccal medication administration?
placing a medication underneath the upper lip or in the side of the mouth
The nurse is teaching a client about venlafaxine XR. When the client asks, "What does the XR mean?" what is the appropriate nursing response?
"It means extended release."
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 right?" The nurse rechecks the CMAR/MAR and finds that the medication is indeed scheduled to be administered. Which response is most appropriate?
"Don't take that pill yet. I will verify the medication order."
The nurse is preparing to administer medications to a client. The client asks, "Why are you using this to give me my medication?" After reviewing the image above, what is the best response by the nurse?
"I am using this machine to scan the code on your wrist to identify and verify the medications prescribed for you before you receive them."
The nurse is administering the first dose of an intravenous infusion of an antibiotic. Which statement made by the client is cause for concern?
"I feel like my back and arms are itching."
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?
"I will get the hospital's information system's phone number for you."
The nurse is instructing a client with xerostomia (dry mouth) about taking several pills and capsules that have been prescribed. What statement made by the client indicates to the nurse that the client understood the instructions?
"I will take a sip or two of water prior to taking my pills."
What is the best response by the nurse when a client asks about the side effects of using nasal spray?
"Long-term use of nasal sprays can cause rebound nasal congestion."
A client with gastritis who is taking aspirin for cardiovascular prophylaxis asks the nurse whether there is benefit in buying the enteric-coated product. What is the appropriate nursing response?
"The enteric coating will protect your stomach."
The nurse is preparing to administer a tuberculin test. At which angle is the nurse expected to instill the drug?
15-degree angle
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?
5 minutes
Which of the following clients would be most likely to beneft from the administration of an otic medication?
A client being treated for an inner ear infection
The client is prescribed a medication that needs to be taken on an empty stomach. The nurse inadvertently administers this medication with food. What are the ramifications of this error?
Absorption of the medication will be impaired.
The nurse has administered a client's first scheduled dose a new analgesic. Thirty minutes later, the client reports nausea and then vomits. The nurse should perform interventions related to what type of drug reaction?
Allergic Effect
The health care provider has prescribed the use of transdermal patch. Which information will the nurse tell the client regarding application?
Apply the patch to a clean, hairless location on the skin.
A nurse gives a client 0.25 mg of digoxin instead of the prescribed dose of 0.125 mg. What should the nurse do next?
Assess the client and notify the client's health care provider.
The nurse observes a prescription written for a client for a medication that does not correlate with the client's diagnosis or comorbid factors. What is the best action for the nurse to take?
Call the provider to obtain a rationale for the use of the medication for the client
A nurse is providing care for a client who has a history of dementia. Which method should the nurse use in order to determine the client's identity prior to medication administration?
Check the clients identification band
The nurse is reading a medication prescription for a drug that is routinely administered every 12 hours. The prescription does not state the frequency of administration. What is the appropriate nursing action and accompanying rationale that guides the nurse's action?
Contact the health care provider to clarify the prescription. Assumptions cannot be made about medication administration and the nurse must practice within the state's nurse practice act and the organization's policies and procedures concerning medication administration.
The hospital nurse is using barcode medication administration software when preparing to administer medication to a client. When the scanning system cannot identify the client's identity, what is the appropriate nursing action?
Contact the pharmacy and information technology department for assistance.
A nurse is administering a hepatitis B immunization injection to an adult client. Which site would the nurse choose for this injection?
Deltoid Muscle site
A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle?
Do not recap the needle; place it in a puncture-resistant container.
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?
Document administration of the medication immediately after administering the drug.
What would be considered a "right" of drug administration? Select all that apply.
Drug Documentation Dose Client
A home care nurse is educating a client with diabetes on how to self-administer insulin. Which teaching point should the nurse include in the education plan?
Each time you give the injection rotate the injection site.
The nurse is reading an order that indicates that a drug is to be given to a client "q4h." How will the nurse administer the medication?
Every 4 hours
A nurse is preparing an injection by withdrawing the solution from a multidose vial. What is necessary to facilitate withdrawing a medication from the vial?
First, inject an equal amount of air into the vial.
The nurse has given a client an injection. How will the nurse prevent an accidental needle stick?
Immediately activate the safety needle and place the syringe and needle into a Sharps container.
The Z-track technique is utilized during drug administration by which route?
Intramuscular
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.
The nurse is caring for a client who has been prescribed an enteric-coated drug. Which should the nurse include when teaching the client proper administration of this drug?
It should not be chewed or crushed.
Which contains all the components of a valid order?
John Smith, atenolol 50 mg, twice a day, by mouth
A nurse preparing medication for a client is called away to an emergency. What should the nurse do?
Lock the medications in a cart and finish them upon return.
The "rights" of medication administration help to ensure accuracy when administering medications. What are some of these rights? Select all that apply.
Medication Client Dosage Route
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?
Obese client
A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?
PRN order
A nurse needs to administer an intradermal injection to a client. What is the nurse's most appropriate action?
Select a 26-27 gauge needle
Which pharmacological consideration should the nurse consider when applying a medication patch to a client?
The nurse is to use gloves to apply and wash hands after.
A postoperative client's medication administration record (MAR) provides for PRN administration of a number of analgesics by various routes. Which action should the nurse take to assess the client's pain to determine the appropriate analgesic to administer?
The nurse will have the client rate pain on the pain scale of 1 to 10 and proceed accordingly.
The nurse has begun caring for a surgical client who has been ordered preoperative antibiotics prior to bowel surgery. While the nurse will adhere to all the principles of safe medication administration, which domain will the nurse pay particular attention to route in this situation?
Time
A client with chronic obstructive pulmonary disease (COPD) has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication?
Use a spacer or extender with the metered-dose inhaler.
After administering medication to a client subcutaneously, the nurse removes the needle at the same angle at which it was inserted. Which explains the nurse's action?
minimizes tissue trauma to the client
The nurse has provided a client with oral medications in a small plastic cup. What is the best nursing action to ensure the rights of safe medication administration are implemented?
Wait with the client until the medications are taken.
Which action made by the nurse demonstrates respect for the client's dignity when administering an intradermal injection?
pulling the curtain or closing the door
A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. What is the reason for bunching when injecting subcutaneously?
to avoid instilling medication within the muscle
A nurse needs to administer a prescribed injection to an older adult client with impaired mobility. Which intramuscular site is preferred for administering an injection to older adult clients?
ventrogluteal
