exam 2
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?
4/10 pain on pain scale, epigastric pain; with reports of nausea
A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?
Ask the client to maintain the position for some time.
A nurse is applying a vaginal cream to a client with a fungal infection. Which guideline is recommended for this application?
Cleanse area at vaginal orifice with washcloth and warm water.
The nurse is preparing to give medications to a client with high blood pressure. The prescription indicates that the client is to have the combination drug dextroamphetamine saccharate-amphetamine aspartate monohydrate-dextroamphetamine sulfate-amphetamine sulfate 40 mg by mouth twice daily. What is the appropriate nursing action?
Contact the health care provider for clarification of the prescription.
Which is an accurate guideline for client teaching regarding the use of a dry powder inhaler (DPI)?
Instruct the client that if mist can be seen from the mouth or nose, the DPI is being used incorrectly.
The nurse just completed a refresher course on parenteral drug administration. Which statement by the nurse indicates that teaching was effective?
Reconstitution is the process of adding liquid, known as diluent, to a powdered substance."
The nurse is administering the first dose of an intravenous infusion of an antibiotic. What action would the nurse take next?
Stay with the client during the first 15 minutes of infusion.
Which is not a purpose of the client care record?
To serve as a contract with the client
Which documentation by the nurse best supports the PIE charting system?
Vomiting 250 mL undigested food, antiemetic given, no further vomiting
A nurse is documenting care in a source-oriented record. What action by the nurse is mostappropriate?
Write a narrative note in the designated nursing section.
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?
aspirating for a blood return
What ensures continuity of care?
communication
The nurse is preparing to administer a tuberculin test. Which route will the nurse select to administer this injection?
intradermal
When administering heparin subcutaneously, the nurse should:
never aspirate.
If the dosage is inappropriate for a client, who is responsible?
nurse
Which medications are dropped into the ear to treat ear infections or to soften and remove ear wax?
otic
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 nursing student regarding safety of chemotherapeutic medication. Which statement by the nurse is correct?
"Antineoplastic drugs can be absorbed through the skin."
A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?
"Medication stays in the chamber so you can continue to inhale it."
Which statement by the nurse would indicate to the charge nurse that there is need for further teaching on the purposes of medical records
"The clients' medical records are an obstruction to research and education."
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 nurse is documenting a progress note that relates to a client's health problem. What form of documentation is the nurse writing?
SOAP note
Which statement best describes the nurse's rationale for selecting the ventrogluteal site when using the Z-track technique for administering an injection?
The ventrogluteal site provides a location with the capacity for depositing and absorbing the drug.
The client states "I think my IV dressing needs to be changed." In which instance should the nurse change the dressing?
When the dressing is loose, bloody or wet
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?
The area is free of major blood vessels and fat
How should the nurse instruct clients to clean their eyes before instilling medications?
Wipe your eyes from the inner canthus toward the outer canthus.
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?
before and after each medication administration
