EAQ questions

in which order will the nurse perform the actions associated with insulin administration

- wash hands with soap and water - rotate the vial of insulin between the palms of the hands - wipe the top of the insulin vial with an alcohol swab - instill air into the vial of insulin equal to the desired dose - withdraw the correct amount of insulin from the inverted vial

The registered nurse is teaching a nursing student about the process of medication reconciliation for a client who was admitted in a health care setting. Which statement made by the nursing student indicates the need for further teaching?

" I would avoid asking about the client's over-the-counter medications."

Which parental statement would the nurse recognize as the approach to administering oral medication to their 4-year-old child?

"I should use a disposable oral syringe to give liquid medicine"

Which statement by a client who is receiving total parenteral nutrition after extensive colon surgery indicates effective teaching

"TPN provides total nutrition when gastrointestinal function is questionable"

How will the nurse respond to a client who expresses concern about air in the piggyback tubing after the nurse piggybacks and IV antibiotic solution into a primary IV line using gravity flow tubing?

"The solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow"

Which instruction would the nurse include in a teaching plan for nitroglycerin patches?

"remove a previous patch before applying the patch to the skin"

How would the nurse prepare an intravenous piggyback (IVPB) medication for administration to a client who has an established IV infusion?

- wear clean gloves to assess the IV site - use a sterile technique when preparing the medication - establish the flow rate for infusion

A health care provider prescribes heparin 6000 unites subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. How many milliliters of heparin will the nurse administer?

0.6mL (6000 units x 1mL/10,000 units = 0.6mL)

Which information would the nurse provide to a client regarding a do-not-resuscitate (DNR) order?

- "do-not-resuscitate orders would be reviewed routinely by the health care provider" - "legally competent adults may issue a do-not-resuscitate order verbally or in writing after receiving proper information about it" - "primary health care providers would check for a DNR order before deciding to perform cardiopulmonary resuscitation"

Which action will the nurse take when a client with an intravenous infusion containing 40 mEg of potassium reports a stinging pain at the IV site?

- assess the IV site - verify that the potassium is adequately diluted and not infusing too rapidly

The nurse understands incorporating which interventions would prevent medication errors?

- avoid using abbreviations and acronyms - minimize the use of verbal and telephone orders - check three times before giving a medication by comparing the medication prescription and medication profile

a client who had been recieving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which type of care will now be removed from the treatment plan?

- chemotherapy - blood transfusion - radiation therapy

The nurse is preparing to administer an ophthalmic medication to a client. Which steps wold the nurse include for this procedure?

- clean the eyelid and eyelashes - apply clean gloves before beginning the procedure - press on the nasolacrimal duct after instilling the solution

when would the nurse observe a client to assess their level of functioning?

- during mealtime - when preparing medication - when administering insulin injections

which action would the nurse perform when a client is in ventricular fibrillation?

- initiating CPR - assessing the EKG - using a defibrillator -obtaining electrolytes -administering epinephrine

Which clinical indicator would the nurse expect when an intravenous line has infiltrated?

- pallor - edema - decreased flow rate

List the actions in the order the nurse will perform them when mixing short-acting and an intermediate-acting insulin in the same syringe

- put air into the intermediate-acting insulin vial - put air into the short-acting insulin vial - withdraw the prescribed amount of short-acting insulin -withdraw the prescribed amount of intermediate-acting insulin

A health care provider prescribes an intermittent enteral tube feeding for a client with a nasogastric tube. Place the nursing interventions in the order in which they should be implemented

- verify the health care providers prescription - elevate the head of the bed to at least 30 degrees - check the volume of residual against the parameters prescribed - administer the volume of feeding as per the prescription - flush the tube with 30ml of water after feeding

The health care provider prescribes lithium citrate liquid 450mg twice a day. The medication is available as 300mg/5mL. How many mL of lithium solution will the nurse administer?

7.5 mL (300mg/5ml= 60mg per 1ml; 450/60mg = 7.5 mL)

A health care provider prescribes 0.2 mg of cyanocobalamin (b12) intramuscularly. A vial of the medication labels 100 mcg = 1mL. How many Ml of solution with the nurse administer?

2mL (0.2mg x 1000 mcg/mg x 1mL /100 mcg = 2mL

Which information about a client who is in cardiac arrest and has been transported by ambulance to the emergency department is most important to communicate to the healthcare provider?

CPR was started 9 minutes after the cardiac arrest (affecting resuscitation, down past 4 min no brain perfusion)

Which condition would the nurse conclude that the client is experiencing when the monitor shows a PQRST wave for each beat, indicates a rate of 120 bpm, and the rhythm is regular

Sinus tachycardia

which measure would the nurse take when administering enoxaparin subcutaneously?

administer in the abdomen

The nurse is providing care to a client who is receiving enteral feedings via a nasogastric (NG) tube. Which serious complication would the nurse take measures to prevent?

aspiration pneumonia

which action would the nurse take first when preparing to teach a client about self-injection of epoetin subcutaneously at home

assess the client's readiness to learn

Which dysrhythmia is this client with weakness, dizziness, and dyspnea exhibiting

atrial fibrillation

Which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin?

avoid massaging the injection site after the injection

In which way would the nurse teach the parent of an 18-month-old child to instill eardrops?

by pulling the pinna down and back to straighten the auditory canal before instillation of the drops

Which action would the nurse take next after the nurse observes a client collapse while walking down the hallway, establishes unresponsiveness, and calls for help?

check for carotid pulse

Which nursing intervention would be the priority for the nurse preparing to administer an intravenous (iv) piggyback medication to a client who is receiving a continuous infusion of IV fluids?

check the compatibility of the medication and the continuous IV solution

Which procedure is used to verify placement of a newly inserted central venous access device (CVAD)?

chest x-ray

Which clinical finding leads to the nurse to conclude that an IV has infiltrated rather than caused inflammation?

coolness

Which intervention is the priority when the nurse in the coronary care unit identifies ventricular fibrillation on a client's cardiac monitor?

defibrillate the client (v-fib=defib)

how would the nurse respond to a client admitted for dehydration who has an intravenous infusion of normal saline is started at 125ml/hr and one hour later begins screaming "I can't breathe"?

elevate the head of the client's bed and obtain vial signs

A client with dementia is discharged home with percutaneous endoscopic gastrostomy (PEG) tube in place. A family member recieves instructions about how to care for the tube. Which action observed by the home health nurse indicates that the family member is effectively managing the client's care?

elevates the head of the bed after feeding

During change of shift report, the night nurse indicates that a client cannot tolerate prescribed intermittent tube feedings. Which action should the receiving nurse take?

gather more data from the night nurse about the technique used

Which intervention would the nurse perform first after finding a client with no pulse?

initiate cardiopulmonary resuscitation (CPR)

Which role would the unlicensed assistive personnel have when caring for a client receiving intravenous therapy

monitoring clinical manifestations (TAPE)

a client has nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. WHich action would the nurse take first?

obtain an x-ray to verify that the tube is in the stomach

Which technique will the nurse teach a client who has a prescription for a sublingual nitroglycerin tablet?

place the pill under the tongue and let it dissolve

A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. Which would the nurse do first

raise the head of the bed; (assist breathing)

After a resection of the colon, a client returns to the surgical unit from the postanestesia care unit with a nasogastric tube attached to negative pressure. Which would the nurse explain is the purpose of this tube?

removes fluids and gas from the upper gastrointestinal tract

Which action would the nurse perform when administering fluticasone propionate to a client with asthma?

rinsing the oral cavity with water after use

Which action will the nurse take when it is time to administer vancomycin to a client with a continuous intravenous heparin drip?

start a second IV line for the vancomycin and continue the heparin as prescribed

Which action would the nurse perform first when assessing if an intravenous infusion of a vesicant has extravasated (solution leaks out of veins and into surrounding tissue)?

stop the infusion

which action would the nurse take when administering iron dextran?

use the z-track method

the medication prescribed for an infant is to be given intramuscularly. Which site will the nurse select for the administration of the medication?

vastus lateralis

Which rhythm would the nurse document when observing the following dysrhythmias on a clients cardiac monitor?

ventricular fibrillation

Which dysrhythmia is this client on the telemetry unit exhibiting?

ventricular tachycardia

Which nurses action would prevent aspiration when administering medications through a nasogastric tube?

verify placement of the nasogastric tube (x-ray)