Exam 3

Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, the nurse must do which of the following? Select all that apply.

Straighten the client's eustachian tube. Gently pull the auricle up and back.

A physician writes an order for a client that says: "Digoxin .125 mg P.O. once daily." To prevent a dosage error, how should the nurse transcribe this order onto the medication administration record?

"Digoxin 0.125 mg P.O. once daily"

A nurse needs to enter into the computer the time the client took medication. However, the time is written in the military format, and the computer accepts only the traditional format. How should the nurse enter the time in the computer if the client took medication at 1530 hours?

03:30 p.m.

A client with osteoarthritis purchased a copper bracelet to wear and tells the nurse that there is less pain now. Which response by the nurse is most appropriate?

Acknowledge that the client feels better, but encourage the client to continue with the prescribed therapy.

ABCDE

Ask Believe Choose Deliver Empower

The nurse is preparing to administer furosemide to a 3-year-old with a heart defect. After verifying the arm band, which is the most appropriate second identifier for the nurse to use?

Ask the parent the child's name.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted.

A client complains of difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take next?

Check for availability of a liquid preparation

The nurse is using the Z-track method of intramuscular (IM) injection to administer iron dextran to a client with iron-deficiency anemia. Which techniques should the nurse use to give this injection? Select all that apply.

Confirm the client's identity before administering the iron dextran. Change the needle after drawing up the iron dextran. Before inserting the needle, displace the skin laterally by pulling it away from the injection site. Inject the iron dextran after aspirating for a blood return.

It is acceptable for the nurse to accept a verbal order from the physician in which of these situations?

During a medical emergency.

A nurse asks a client who had abdominal surgery 3 days ago if they have moved their bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate at least three times per day.

As a nurse-manager of a medical-surgical unit reviews the month's risk-management data, she notices that a number of incident reports were completed because 6 p.m.(1800) medications were administered late. Dinner is served between 5:30 p.m. (1730) and 6 p.m. (1800). Staff take their dinner breaks between 5 p.m. (1700) and 6:30 p.m.(1830). Based on this information, which is the most appropriate action for the nurse-manager to take?

Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m. (1800), and staff availability between 5 p.m. (1700) and 6 p.m. (1800).

What is one disadvantage of using the rectal route?

It can result in incomplete drug absorption.

Which technique is correct when the nurse is inserting a rectal suppository for an adult client?

Position the suppository along the rectal wall.

A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?

Remind the LPN that it is the LPN's duty to administer the medications.

A nurse is preparing to administer cardiac medications to two clients with the same last name. The nurse checks the medication three times before entering the room to administer medications to the first client. While leaving the room, the nurse realizes they didn't check the client's identification before administering the medication. Which action should the nurse take first?

Return to the room, check the client's identification against the medication administration record, and complete a variance report if needed.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

Standing Order

The nurse is observing a new graduate nurse instill eyedrops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which step is incorporated into the procedure?

The nurse's hand is stabilized on the client's forehead while instilling the drops.

Which client would benefit from the application of warm moist heat?

a client with low back pain

Which drug delivery system most effectively reduces the likelihood of medication errors?

automated

Which intramuscular (IM) sites are appropriate for the nurse to use in an adult client? Select all that apply.

dorsogluteal muscle deltoid muscle vastus lateralis muscle rectus femoris muscle

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

laxative

A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as

moxifloxacin 400 mg daily

A nurse who fails to check a client's armband before administering medications is:

negligent.

The nurse transcribes the physician's order onto the client's medication record: September 15, 20XXAdminister 10 gtt of timolol maleate ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply.

number of drops route

OPQRSTU

onset provocative/palliative quality/quantity region/radiation severity timing understanding

The second morning after surgery for a below-the-knee amputation of the left leg, the client says, "This sounds crazy, but I feel my left toes tingling." This statement would indicate to the nurse that he is experiencing a:

phantom-limb sensation.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which would be the most appropriate action for the nurse?

strike out with a single line and place initials

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

the prescriber

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. What are purposes of the "read-back" requirement? Select all that apply.

to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?

unauthorized entry

The nurse is preparing to give an IM injection. to an underweight client. Which site is the safest because it has the fewest amount of blood vessels and major nerves located in the area?

vastus lateralis

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain." The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Stool softeners can decrease pain with defecation, but clients should discuss their use with their provider before taking them. Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining and subsequent hemorrhoidal development or enlargement.

What is the maximum amount of medication (in milliliters) that can be administered into the deltoid muscle? Record your answer using a whole number.

2

How long to reassess IV pain med admin?

30 minutes

The nurse gave the client the wrong medication. It is 2 hours later when the nurse realizes the error. What should the nurse do first?

Assess the client's condition.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first?

Assess the pain using a pain scale and compare to the previous assessment.

Which finding would indicate bowel functioning is returning after anesthesia and surgery for a client with a nasogastric tube?

Auscultation indicates bowel sounds in all four quadrants.

The nurse is preparing to administer IM morphine sulfate to a client who is in pain. On checking the health care provider's (HCP's) prescription, the nurse notes that the prescription states, "morphine sulfate 60 mg IM every 4 hours as needed for pain." The usual dose of morphine is 10 to 15 mg. What is the most appropriate action for the nurse to take?

Contact the HCP to verify the prescription.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

Document the client's choice and re-assess pain in 1 hour.

An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the best action for a nurse to take in caring for this dying adolescent?

Give the adolescent more pain medication to control pain and suffering.

The unit secretary who transcribes the health care provider's (HCP's) prescriptions asks the nurse to interpret an illegible prescription. The nurse should clarify the prescription with the:

HPC

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?

Inspect the infusion site.

what is the most common type of pain?

Nociceptive Occurs when pain receptors respond to potentially damaging stimuli

A child is admitted with constipation and a diagnosis of possible appendicitis. The child is in acute pain. Which nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.

Offer an ice pack. Assume a position of comfort. Limit the child's activity.

A client has requested to have patient-controlled analgesia (PCA) after surgery? When is it appropriate for a client to receive PCA?

The client has the ability to self-administer.

Which teaching instructions by the nurse is appropriate for a client with constipation?

The client will consume foods high in fiber.

A physician's order for a client states the administration of a medication "b.i.d." How many times should the nurse administer the medication to the client?

Twice a day

A client reports being allergic to amoxicillin even though the medication administration record and armband do not indicate medication allergies. What should the nurse do about administering the drug to the client?

Withhold the medication.

Which procedures can the nurse working on a pediatric floor safely delegate to the licensed practical/vocational nurse (LPN/VN)? Select all that apply.

administering gastrostomy tube feedings inserting hearing aids

The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?

an orange, raisin bran and milk, and wheat toast with butter

After receiving an I.M. injection, a client complains of burning pain at the injection site. Which nursing action would be most appropriate at this time?

applying a warm compress to dilate the blood vessels

When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to." What intervention by the nurse would have the highest priority?

exploring how the client's feelings affect the decision to refuse medication

The correct procedure for auscultating the client's abdomen for bowel sounds is to:

listen for 5 minutes in all four quadrants to confirm absence of bowel sounds.

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client?

use of all drugs taken in the last 18 months

A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching?

"I should limit my fiber intake for 1 to 2 weeks following the procedure." There's no need to limit fiber intake after a barium enema. The client may resume his normal diet. Barium may increase stool elimination, so there's no need for a laxative after the procedure. The client should increase fluid intake to facilitate barium elimination. The client should report bowel movements so the nurse can ensure that barium elimination occurs.

An adolescent client who has been taking an antidepressant for 6 weeks has returned to the clinic for a medication check. When the nurse talks with the client and her parent, the mother reports that she has to remind the client to take her antidepressant every day. The client says, "Yeah, I'm pretty bad about remembering to take my meds, but I never miss a dose because Mom always bugs me about taking it." Which response would be effective for the nurse to make to the client?

"It seems there are some difficulties with being responsible for your medications that we need to address".

A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective?

"My ankle looks less swollen now."

A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath?

Administer an analgesic.

Which intervention is an example of primary prevention?

Administering a measles, mumps, and rubella immunization to an infant

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

To give a Z-track injection, a nurse measures the correct medication dose and then changes the needle on the syringe. What is the rationale for this action?

Changing the needle makes the injection less painful.

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber.

An infant received the wrong medication dose. What is the charge nurse's role in following up on the incident?

Objectively assess the circumstances surrounding the error.

A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take?

Report the situation to the nursing supervisor.

The nurse notes that a client's blood glucose level is increased. The nurse plans to inform the physician by phone. Which technique should the nurse use to communicate verbally to the physician?

SBAR

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which observations indicates that the client is using the MDI correctly? Select all that apply.

The inhaler is held upright. The client rinses the mouth with water following administration.

A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base the next action on which understanding?

The nurse should clarify the order with the physician.

A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain?

Use a bed cradle to keep linens from pressing on the child's joints.

The nurse is preparing to administer ear drops to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication? Select all that apply.

Wash hands and arrange supplies at the bedside. Warm the medication to the body temperature. Examine the ear canal for drainage.

A nurse is caring for a client with history of chronic intestinal irritation. The client asks, "Is there any type of colostomy where I would not need a continuous colostomy bag?" Indicate the location where a client could have an ostomy that eventually might not require wearing an ostomy bag.

With a sigmoid colostomy, the feces are solid; therefore, the client may eventually gain enough control that they would not need to wear a colostomy bag. With a descending colostomy, the feces are semi-mushy. With a transverse colostomy, the feces are mushy. With an ascending colostomy, the feces are fluid. In these three latter cases, it's unlikely that the client could gain control of elimination; consequently, wearing an ostomy bag would be necessary.

A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:

a diminished response to a drug so that more medication is required to achieve the same effect.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be

administering pain medication.

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's

adverse effects.

A nurse preparing to administer medications on the respiratory floor is using the computerized medication-dispensing system. Her password isn't working. The nurse should:

ask computer support to reset her password.

A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relive pain? Massage therapy:

blocks pain impulses from the spinal cord to the brain.

A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing?

bupivacaine with epinephrine used as the local anesthetic.

A client who recently immigrated from Korea to the US or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?

checking vital signs and assessing for nonverbal indications of pain

A client on the genitourinary floor has refused all medications for 3 days. A nurse caring for this client asks why he isn't complying with his medication. The client states, "I don't want to take those pills anymore." The nurse informs the client that he must take all the medication the physician orders. With this statement, the nurse has violated the:

client's right to refuse medication.

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?

colonoscopy with biopsy

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.

Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply.

medical record number name band

neuropathic pain

pain from damage to neurons of either the peripheral or central nervous system

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

The nurse is teaching a client about using topical gentamicin sulfate. Which comment by the client indicates the need for additional teaching?

"I should apply it to large open areas."

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy."

Gentamicin sulfate 25 mg IM has been ordered every 6 hours. Gentamicin sulfate 40 mg/mL is available. How many milliliters (to the nearest tenth of a mL) should the nurse administer in each dose?

0.6

A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information?

1 Unit of glucose

The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. What should the nurse do next?

Contact the pharmacist immediately to check the order and the barcode label for accuracy.

The nurse is preparing to administer the last dose of ceftriaxone before discharge to a 1-year-old but finds the IV has occluded. What should the nurse do/?

Contact the prescriber to request a prescription change.

The nurse is preparing to administer a flu shot to an elderly client. How should the nurse proceed? Place the steps in sequential order. Use all the options.

Correct response: Put gloves on. Locate the deltoid muscle. Clean the injection site with an alcohol pad. Expel air bubbles from the syringe. Gently stretch the skin taut at the sites. Inject it into the muscle at a 90-degree angle.

The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). What additional signs should the nurse assess?

deep vein thrombosis (DVT) in the left leg.

A client is using healing touch therapy to manage pain. What should the nurse tell the client about how healing touch can be effective in pain management?

directing the flow of energy fields.

The nurse manager on a pediatric floor is updating safety recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.

Avoid using parenteral syringes when administering liquid oral medications. Limit the size of IV fluid bags that can be hung on small children. Reduce the available concentrations or dose strengths of high-alert medications to the minimum.

A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as

0800 and 2000

The nurse is taking care of a client with a spinal cord injury. The extent of the client's injury is shown in the accompanying image. Which finding is expected when assessing this client?

dysfunction of bowel and bladder

Which nursing intervention is most important in preventing postoperative complications?

early ambulation

How long to reassess PO pain med admin?

60 min

Transduction

activation of nociceptors by stimui

The nurse is preparing to administer 4 units of regular insulin to a client with type 1 diabetes mellitus. Which equipment does the nurse need to perform the injection? Select all that apply.

Medication administration record 27-gauge, ½" needle

The wife of a terminally ill client asks the nurse, "Why is my husband having frequent bowel movements if he is not eating?" What should the nurse tell the wife?

"The intestines still produce some waste products even when a person is not eating."

After teaching the client how to use the patient-controlled analgesia (PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement?

"The machine will give me only the prescribed amount of pain medication even if I push the button too soon."

Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?

"When did you last have a bowel movement?"

When planning pain control for a client with terminal gastric cancer, a nurse should consider that

clients with terminal cancer may develop tolerance to opioids.