Essentials Exam 2 Questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
SATA
answer
select all that apply - just so know what is meant in the cards
question
When preparing to administer a new medication, what would the nurse do first to ensure the patient's safety? A. Perform hand hygiene. B. Compare the written order with the medication administration record (MAR). C. Inform the patient about the medication. D. Review appropriate nursing considerations.
answer
B. Compare the written order with the medication administration record (MAR).
question
What is the most important step the nurse can take to ensure that the patient is getting the correct medication? A. Assess the patient's ability to swallow oral medications without difficulty. B. Question the patient about his or her experience with this or similar medications. C. Compare the medication label with the MAR three times. D. Evaluate the patient's understanding of the safety issues related to the specific drug.
answer
C. Compare the medication label with the MAR three times.
question
Which statement or question best illustrates the nurse's understanding of the role of NAP in medication administration? A. "Does the patient need her pain medication?" B. "Let me know if she complains of any nausea." C. "What is the quality of her pain now?" D. "Tell her she doesn't have an order for the drug she's asking for."
answer
B. "Let me know if she complains of any nausea."
question
As the nurse is administering medication to a patient, the patient states, "I've never seen that pill before." What is the nurse's most appropriate response? A. Reassure the patient that the pharmacy sent the right medication. B. Tell the patient that it is probably a different brand than what he takes at home and not to worry. C. Tell the patient that you will review the physician's order to clarify any discrepancies. D. Tell the patient that the doctor probably ordered a new medication.
answer
C. Tell the patient that you will review the physician's order to clarify any discrepancies.
question
What is the nurse's best response after noticing that the route of administration has been omitted from a medication order? A. Ask which route the patient prefers. B. Immediately notify the prescriber to request that the order be completed. C. Refer to a current drug book to determine the most commonly prescribed route. D. Contact the pharmacy to determine the most appropriate route for this patient.
answer
B. Immediately notify the prescriber to request that the order be completed.
question
The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? A. Call a pharmacist to interpret the order B. Call the physician to have the order clarified C. Consult the unit manager to help interpret the order D. Ask the unit secretary to interpret the physician's handwriting
answer
B. Call the physician to have the order clarified
question
The pt has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? A. 2mL B. 5mL C. 16mL D. 30mL
answer
D. 30mL
question
A pt is to receive cephalexin (Keflex) 500mg PO. The pharmacy has sent 250mg tablets. How many tablets does the nurse administer? A. 1/2 tablet B. 1 tablet C. 1 1/2 tablets D. 2 tablets
answer
D. 2 tablets
question
A nurse is administering eardrops to an 8 y/o pt with an ear infection. How does the nurse pull the pts ear when administering the medication? A. Outward B. Back C. Upward and outward D. Upward and back
answer
C. Upward and outward
question
A nurse is administering meds to a 4 y/o pt. After he/she explains which meds are being given, the mother states, "I don't remember my child having that med before." What is the nurse's next action? A. Give the meds B. Identify the pt using 2 identifiers C. Withhold the meds and verify the med orders D. Provide med education to the mother to help her better understand her child's meds
answer
C. Withhold the meds and verify the med orders
question
A nursing student takes a pts antibiotic to the pts room.The pt asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the pt? A. Only the pts physician can give this information B. The student provides the name of the medication and a description of its desired effects C. info about meds are confidential and can't be shared D. He has to speak with his assigned nurse about this
answer
B. The student provides the name of the medication and a description of its desired effects
question
A pt is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe med administration for the discharge nurse? A. Set up the follow-up appointments with the physicians for the pt B. Ensure someone will provide housekeeping for the pt at home C. Ensure that the home care agency is aware of meds and health teaching needs D. Make sure that the pts family knows how to safely bathe him or her and provide mouth care
answer
C. Ensure that the home care agency is aware of meds and health teaching needs
question
The nurse is adminstering a sustained-release capsule to a new pt. The pt insists that he can't swallow pills. What is the nurse's best next course of action? A. Ask the prescriber to change the order B. Crush the pill with a mortar and pestle C. Hide the capsule in a solid piece of food D. Open the capsule and sprinkle it over pudding
answer
A. Ask the prescriber to change the order
question
A nurse takes a med to a pt, and the pt tells them to take it away because she is not going to take it. What is the nurse's next action? A. Ask the pts reason for refusal B. Explain that she must take the meds C. Take the meds away and chart the pts refusal D. Tell the pt that her physician knows what is best for her
answer
A. Ask the pts reason for refusal
question
The nurse receives an order to start giving a loop diuretic to a pt to help lower his or her bp. The nurse determines the appropriate route for administering the diuretic according to: A. Hospital policy B. The prescriber's orders C. The type of meds ordered D. the pts size and muscle mass
answer
B. The prescriber's orders
question
A pt is receiving an IV push med. If the drug infiltrates into the upper tissues, the nurse: A. Continues to let the IV run B. Applies a warm compress to the infiltrated site C. Stops the administration of the meds and follows agency policy D. Should not worry about this because vesicant filtration is not a problem
answer
C. Stops the administration of the meds and follows agency policy
question
If a pt who is receiving IV fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: A. Sepsis B. Phlebitis C. Infiltration D. Fluid overload
answer
B. Phlebitis
question
After seeing a pt, the physician gives a nursing student a verbal order for a new med. The nursing student first needs to: A. Follow ISMP guidelines for safe med abbreviations B. Explain to the physician that the order needs to be given to a RN C. Write down the order on the pts order sheet and read it back to the physician D. Ensure the 6 rights of pt administration are followed when giving the meds
answer
B. Explain to the physician that the order needs to be given to a RN
question
A nurse accidentallly gives a pt a med at the wrong time. The nurse's first priority is to: A. Complete the occurrence report B. Notify the health care provider C. Inform the charge nurse of the error D. Assess the pt for adverse effects
answer
D. Assess the pt for adverse effects
question
A pt is taking albuterol through a pressurized metered-dose inhaler (pMDI) that contains a total of 200 puffs. The pt takes 2 puffs every 4 hrs. How many days will the pMDI last?
answer
16
question
How might the nurse safely administer an extended-release capsule to a patient with dysphagia? A. Encourage the patient to drink plenty of water when swallowing the capsule. B. Open the capsule, and place the contents into 90 mL (3 fl. oz.) of juice. C. Place the capsule in a spoonful of the patient's applesauce. D. Save the capsule to be administered last.
answer
C. Place the capsule in a spoonful of the patient's applesauce.
question
The nurse is preparing to administer several oral medications when the patient says he would like to take his pills with orange juice. What is the nurse's best response? A. Determine whether the patient's prescribed diet includes orange juice. B. Establish whether the medications may be taken with orange juice. C. Ask the dietary aide to order extra orange juice for the unit. D. Administer the pills with orange juice.
answer
B. Establish whether the medications may be taken with orange juice.
question
Which statement or question best illustrates the nurse's understanding of the role of NAP in administering oral medications? A. "Does the patient need her pain medication?" B. "Please make sure the patient has plenty of fresh water to take with her pills." C. "How much did the pain medication improve her pain?" D. "Stay with the patient until he swallows all the pills."
answer
B. "Please make sure the patient has plenty of fresh water to take with her pills."
question
The nurse has provided a patient with a prn oral analgesic that may be repeated as needed every 6 to 8 hours. What is the most appropriate follow-up action to ensure appropriate pain management? A. Reassess the patient's pain in 30 to 40 minutes. B. Document the patient's request for pain medication. C. Administer the pain medication again in 6 hours. D. Include the patient's pain history in the end-of-shift nursing report.
answer
A. Reassess the patient's pain in 30 to 40 minutes.
question
A patient with a history of nighttime confusion is to receive several oral medications at bedtime. What is the best way for the nurse to ensure that the patient has swallowed the medication? A. Administer each tablet individually. B. Observe the patient closely as he swallows the tablets. C. Ask the patient to open his mouth after swallowing each tablet. D. Ask the patient to swallow a full glass of water with the tablets.
answer
C. Ask the patient to open his mouth after swallowing each tablet.
question
Which example reflects effective documentation of medication administration by a nurse? A. Comparing the written order with the medication administration record (MAR) three times B. Providing patient education regarding a medication C. Obtaining a BP before giving a blood pressure medication D. Including the location of an injection site on the medication administration record
answer
D. Including the location of an injection site on the medication administration record
question
What is the best way for the nurse to ensure that a patient receives the correct dose of a medication? A. Compare the prescriber's order with the medication administration record before dispensing the medication B. Ask the patient if he would like a larger dose of pain medication C. Assess the patient's ability to swallow oral medications without difficulty D. Check the name of the medication three times against the medication administration record
answer
A. Compare the prescriber's order with the medication administration record before dispensing the medication
question
Which statement best illustrates the nurse's understanding of the role of NAP in documenting medication administration? A. "Make a note that the patient just received her pm dose of pain medication." B. "Let me know if she says her nausea is getting worse." C. "Can you check the MAR and see when this patient had her pain med last?" D. "Ask the patient if I need to get another order from the provider."
answer
B. "Let me know if she says her nausea is getting worse."
question
The patient refuses the scheduled dose of an antibiotic, saying that the medication makes him feel nauseated. What it the nurse's best response? A. Informing the patient why the medication is necessary B. Notifying the prescriber of the patient's reason for refusing the medication C. Offering to administer the medication with the patient's favorite snack food D. Noting the patient's refusal in the medication administration record (MAR)
answer
B. Notifying the prescriber of the patient's reason for refusing the medication
question
While reviewing a new medication order, the nurse notes that the frequency of administration has been omitted. What is the nurse's best response? A. Immediately contacting the prescriber to complete the order B. Referring to a current drug book for the most commonly prescribed dosage C. Calling the pharmacy to determine the frequency D. Asking a registered nurse who is familiar with the prescriber to identify the usual frequency ordered
answer
A. Immediately contacting the prescriber to complete the order
question
As the nurse is at the bedside preparing to administer a new medication, the patient mentions that he is allergic to the drug. What will the nurse do first? A. Notify the physician B. Withhold the medication C. Check to see if the patient is wearing a red allergy ID band D. Review the medication administration record (MAR) for allergies
answer
B. Withhold the medication
question
As the nurse prepares to administer oral acetaminophen, the patient refuses to accept the drug because it doesn't look like the Tylenol she takes at home. After verifying that the medication and dosage are correct, what is the nurse's best response? A. Informing the patient that the medication is a form of Tylenol B. Explaining that she will probably have increased pain if she refuses the medication C. Showing the patient a picture of the medication D. Explaining that drugs often come in different physical forms, depending on the manufacturer
answer
D. Explaining that drugs often come in different physical forms, depending on the manufacturer
question
What is the nurse's first response when a patient requests another dose of narcotic pain medication before it is time for the next dose? A. Consulting with the physical therapy department to arrange for a visit with the patient B. Working with the patient to find alternative nonpharmacologic means of pain management C. Contacting the patient's provider to request an order for additional pain medication D. Giving the patient a detailed explanation of the need to limit the amount of narcotic medication she takes
answer
B. Working with the patient to find alternative nonpharmacologic means of pain management
question
The patient has requested a PRN medication for nausea. Which of the following should the nurse do first? A. Offer dry crackers and ice chips if not contraindicated B. Ask the patient about his allergies C. Explain the specific purpose of the medication D. Check to see when the medication was given last and make sure the time interval is up
answer
D. Check to see when the medication was given last and make sure the time interval is up
question
After requesting a narcotic pain medication, the patient refuses it after the nurse prepares the injection. What is the nurse's best initial response? A. Ask the patient the reason for his refusal B. Notify the physician and asking for a different type of pain medication C. Have another registered nurse witness the proper discarding of the drug D. Explain to the patient the need to manage pain effectively
answer
A. Ask the patient the reason for his refusal
question
When is a patient at a higher risk for a medication administration error? A. During a care transition point, such as transfer to another unit B. While on a hospital unit for an extended length of time C. On the third postoperative day D. When taking an active role in self-administration of insulin
answer
A. During a care transition point, such as transfer to another unit
question
As the nurse is giving a patient his medications, he remarks, "I've never seen this blue pill before." What is the nurse's correct response? A. "I'm sure the doctor knows what he's doing. Don't worry." B. "Our pharmacy probably sent a generic form of what you're used to taking." C. "What color pill are you used to seeing?" D. "Don't take it. Let me double-check the doctor's order to make sure this is the correct medication for you."
answer
D. "Don't take it. Let me double-check the doctor's order to make sure this is the correct medication for you."
question
What is the best way for the nurse to ensure that the patient does not receive the wrong dose because of a calculation error? A. Ask the pharmacy to calculate the correct dosage. B. Consult a current drug book to determine the new dosage. C. Defer the calculation process to the provider. D. Ask another registered nurse to verify the calculation.
answer
D. Ask another registered nurse to verify the calculation.
question
Which of the following nursing actions will reduce the risk of "wrong route" when administering a medication? A. Only splitting pills or tablets that have been prescored by the manufacturer B. Using an oral dosing syringe when administering oral liquid medication C. Transcribing a fractional dose of less than one with a leading zero (e.g., 0.5 mg) D. Crushing an oral medication that is difficult to swallow
answer
B. Using an oral dosing syringe when administering oral liquid medication
question
What is the most appropriate way for the nurse to split an unscored tablet? A. Use a pill-splitting device to split an unscored pill in half. B. Ask the pharmacy if it is appropriate to split the pill and if so, ask them to split and repackage it with the adjusted dose given on the label. C. Use scissors to cut the pill in half. D. Administer a whole pill every other day instead of every day.
answer
B. Ask the pharmacy if it is appropriate to split the pill and if so, ask them to split and repackage it with the adjusted dose given on the label.
question
What is the nurse's first step in preparing to administer a prescribed medication using an automated medication dispensing system? A. Establish the patient's ID using two identifiers B. Review the medication administration record (MAR) C. Provide patient education D. Review applicable nursing considerations
answer
B. Review the medication administration record (MAR)
question
Which precaution should the nurse observe to ensure patient safety when using an automated medication dispensing system? A. Assess the patient's ability to swallow oral medications without difficulty B. Ask the patient about his or her experience with this or similar medications C. Prepare medications for one patient at a time D. Evaluate the patient's understanding of the safety issues related to the specific drug
answer
C. Prepare medications for one patient at a time
question
Which statement or question best illustrates the nurse's understanding of the role of NAP in using medication dispensing systems? A. "Does the patient need her pain medication?" B. "Let me know if she complains of any nausea." C. "Ask her to describe her pain and show you where it is." D. "Remember to log off of the system when you are finished."
answer
B. "Let me know if she complains of any nausea."
question
Which action by a nurse is most important in protecting the safety of patients and staff when using an automated medication dispensing system? A. Refusing to share his or her individual security log-in code for the dispensing system B. Having another registered nurse check his or her mathematical calculations C. Reviewing a current drug book for dosing information D. Using two different mathematical formulas to cross-check a dosage calculation
answer
A. Refusing to share his or her individual security log-in code for the dispensing system
question
While preparing a patient's oral medication dispensed from an automatic system, the nurse realizes that the pill dispensed is twice the required dose. What is the nurse's best response? A. Notify the health care provider and ask if the higher dose could be given B. Access the dispenser again for the appropriate dose C. Notify the pharmacy to determine if the accurate dose is available D. Splitting the pill in half
answer
C. Notify the pharmacy to determine if the accurate dose is available
question
What is the greatest safety concern when withdrawing medication from an ampule? A. Not wearing gloves when preparing medication B. Selecting an inappropriate needle size C. Withdrawing glass particles into the syringe D. Withdrawing bubbles into the syringe
answer
C. Withdrawing glass particles into the syringe
question
How does the nurse minimize the risk of patient infection when preparing medication from an ampule? A. Using a filter needle to draw up the medication B. Preparing the medication in the patient's room C. Applying clean gloves while preparing the medication D. Preserving the sterility of the needle while preparing the medication
answer
D. Preserving the sterility of the needle while preparing the medication
question
Which action minimizes the risk of introducing glass particles into the syringe when drawing medication from an ampule? A. Using minimal force to snap the neck of the ampule B. Using gauze to cover the top of the ampule when snapping it C. Using a filter needle or straw to draw the medication from the ampule D. Allowing the medication to settle after the ampule has been snapped open
answer
C. Using a filter needle or straw to draw the medication from the ampule
question
Which action might the nurse take when drawing up medication from an ampule? A. Hold the ampule upside down while inserting the filter needle. B. Inject air into the ampule before withdrawing the medication. C. Hold the ampule horizontally while inserting the filter needle. D. Expel air bubbles from the syringe while the filter needle is still inside the ampule.
answer
A. Hold the ampule upside down while inserting the filter needle.
question
A nurse is preparing to withdraw medication from an open multidose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, what would the nurse do next? A. Apply clean gloves. B. Vigorously shake the vial. C. Wipe the rubber seal of the vial with an alcohol swab. D. Introduce air equal to the amount of medication needed.
answer
C. Wipe the rubber seal of the vial with an alcohol swab.
question
What would the nurse do to remove air trapped in a syringe before withdrawing the syringe from the vial? A. Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe. B. Position the tip of the needle below the fluid line, and tap the vial. C. Position the vial on a flat surface, and tap the syringe. D. Position the syringe above the vial, and tap the vial.
answer
A. Position the tip of the needle in the vial's airspace, and tap the barrel of the syringe.
question
How can the nurse prevent negative pressure from building up in the vial when preparing an injection? A. Inject an amount of air into the vial equivalent to the volume of medication to be withdrawn. B. Insert the needle through the center of the rubber seal. C. Keep the tip of the needle below the level of fluid in the vial. D. Tap the barrel of the syringe to dislodge air bubbles.
answer
A. Inject an amount of air into the vial equivalent to the volume of medication to be withdrawn.
question
How can the nurse ensure that medication from a single-dose vial is used appropriately? A. Check to see when the medication vial was opened initially. B. Write the date and his or her initials on the label when opening the vial. C. Draw the entire amount of medication from the vial into the syringe. D. Discard the vial and any remaining medication in the vial directly after use.
answer
D. Discard the vial and any remaining medication in the vial directly after use.
question
What will the nurse do after opening a multidose vial and withdrawing a dose of medication from it? A. Discard the unused portion of the medication. B. Wipe the entire vial with an antiseptic swab. C. Send the unused portion back to the pharmacy. D. Label the vial with the date it was opened and your initials.
answer
D. Label the vial with the date it was opened and your initials.
question
How can the nurse best ensure the patient's safety when preparing insulin for administration? A. Obtain the patient's current blood glucose level. B. Clean the injection site with an antibacterial swab. C. Apply clean gloves. D. Wipe the rubber seal of the vial with alcohol.
answer
A. Obtain the patient's current blood glucose level.
question
How would the nurse prepare insulin to ensure its efficacy? A. Do not allow refrigerated insulin to warm up before administering it. B. Follow aseptic technique during the entire process. C. Roll the vial of insulin suspension between the palms prior to drawing up the medication. D. Monitor the patient's blood glucose level before administering the injection.
answer
C. Roll the vial of insulin suspension between the palms prior to drawing up the medication.
question
When will a patient's blood glucose levels be most affected by a short-acting insulin injection, such as Humulin-R? A. In 2 to 3 hours B. For the next 12 hours C. During unplanned exercise D. When the patient eats carbohydrates
answer
A. In 2 to 3 hours
question
Which of the following statements is accurate regarding insulin administration? A. Vials of insulin may be stored in the freezer to extend their shelf life. B. If the rapid-acting insulin ordered is unavailable, it is safe to substitute an alternative rapid-acting insulin. C. Vials of insulin must be inspected before each use for changes in appearance. D. All insulin must be shaken before use to redistribute particles within the suspension.
answer
C. Vials of insulin must be inspected before each use for changes in appearance.
question
To prevent hypoglycemia and enhance efficacy, it is appropriate to give rapid-acting insulin how many minutes before the next meal? A. 5 to 15 minutes B. 30 to 40 minutes C. 60 to 90 minutes D. The timing of insulin around meals is not necessary.
answer
A. 5 to 15 minutes
question
The nurse is preparing to mix short- and intermediate-acting insulins to administer to a patient. Which action best preserves the insulin's effectiveness? A. Determining the patient's blood glucose level B. Refraining from injecting the intermediate-acting insulin into the short-acting vial C. Applying clean gloves when administering the medication D. Having another registered nurse verify the dose of both types of insulins
answer
B. Refraining from injecting the intermediate-acting insulin into the short-acting vial
question
The patient is to receive both Lantus® (insulin glargine) and regular insulin. To ensure the proper action of the insulins, what would the nurse do when preparing these two types of insulin for administration? A. Mix the insulins in one syringe for a single injection. B. Prepare the insulins in two syringes for separate injections. C. Roll each vial between the palms to disperse the medication within the suspension. D. Have another registered nurse verify the dose of the insulins.
answer
B. Prepare the insulins in two syringes for separate injections.
question
When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection? A. Insert air into the intermediate-acting insulin. B. Warm the vials to room temperature. C. Shake the vials to disperse the medication within the suspension. D. Withdraw the prescribed amount of short-acting insulin after the intermediate-acting insulin.
answer
A. Insert air into the intermediate-acting insulin.
question
When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe? A. By noting when 5 units of clear insulin is visible in the syringe B. By noting when 12 units of cloudy insulin is visible in the syringe C. By having another registered nurse verify the presence of 17 units of insulin D. By verifying that the prescription confirms the medication administration record (MAR)
answer
A. By noting when 5 units of clear insulin is visible in the syringe
question
Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe? A. Draw the intermediate-acting insulin into the syringe first. B. Draw the long-acting insulin into the syringe first. C. Prepare two injections. D. Draw either the intermediate- or the long-acting insulin into the syringe first.
answer
C. Prepare two injections.
question
When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? A. Aspiration of blood prior to injecting the medication B. Inability to feel resistance when injecting the medication C. Formation of a 6-mm bleb at the injection site D. Appearance of a lesion resembling a mosquito bite at the injection site
answer
B. Inability to feel resistance when injecting the medication
question
Which statement might the nurse make to NAP when caring for a patient who is prescribed an intradermal injection? A. "Be sure to wear clean gloves during the injection." B. "Tell him it's OK; the site should look like a mosquito bite." C. "Immediately report any patient complaints of itching or dyspnea." D. "Remind the patient to come back in 48 to 72 hours so we can evaluate the site."
answer
C. "Immediately report any patient complaints of itching or dyspnea."
question
Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? A. A raised wheal the size of a mosquito bite B. A bruised area 10 mm or greater in diameter C. A hard, raised area 15 mm or greater in diameter D. A flat, reddened area 5 mm or greater in diameter
answer
C. A hard, raised area 15 mm or greater in diameter
question
In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness
answer
C. Right deltoid of a high school softball pitcher
question
How can the nurse determine that the needle tip for an intradermal injection is in the dermis? A. A bleb the size of a mosquito bite will appear. B. The needle will enter at a 5- to 15-degree angle. C. The bulge of the needle tip will be visible through the skin. D. The needle will penetrate through the epidermis to a depth of about ⅛ inch.
answer
C. The bulge of the needle tip will be visible through the skin.
question
Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? A. Massage the site after administration. B. Make sure the volume of the medication is less than 2 mL. C. Administer the injection at a 45- to 90-degree angle. D. Wear clean gloves while administering the injection.
answer
B. Make sure the volume of the medication is less than 2 mL.
question
Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? A. 20-gauge, ½-inch B. 22-gauge, 1-inch C. 25-gauge, ⅜-inch D. 27-gauge, 1-inch
answer
C. 25-gauge, ⅜-inch
question
What can the nurse do to minimize the discomfort of a subcutaneous injection? A. Inject the medication rapidly. B. Massage the injection site. C. Cover the injection site with gauze pad after withdrawing the needle. D. Inject the medication without pinching the skin.
answer
C. Cover the injection site with gauze pad after withdrawing the needle.
question
When preparing to administer heparin or insulin subcutaneously, which site is preferred? A. Abdomen B. Scapula C. Deltoid muscle D. Back of the upper arm
answer
A. Abdomen
question
What can the nurse do to ensure proper site selection for subcutaneous insulin injection? A. Insert the needle at a 30-degree angle. B. Select a different anatomical region for each injection. C. Ask the patient to relax before inserting the needle. D. Systematically rotate sites within the same anatomical location or area.
answer
D. Systematically rotate sites within the same anatomical location or area.
question
Which action by the nurse ensures patient safety when administering an intramuscular injection? A. Putting on clean gloves before administration B. Rotating injection sites C. Aspirating for blood return when administering a vaccine D. Injecting the medication quickly
answer
B. Rotating injection sites
question
When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection? A. Wear clean gloves. B. Use a 3-mL syringe. C. Clean the injection site with an alcohol swab. D. Massage the injection site.
answer
C. Clean the injection site with an alcohol swab.
question
What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? A. Instruct the patient to relax. B. Insert the needle at a 45-degree angle. C. Pull back on the plunger after inserting the needle. D. Pull the skin taut at the injection site when inserting the needle.
answer
C. Pull back on the plunger after inserting the needle.
question
Which site is most commonly used for intramuscular injections? A. Ventrogluteal B. Abdominal C. Deltoid D. Dorsogluteal
answer
A. Ventrogluteal
question
Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? A. Using a 1-inch needle B. Inserting the needle at a 45- to 60-degree angle C. Withdrawing the needle immediately after delivering the medication D. Aspirating for blood return before injection medication
answer
D. Aspirating for blood return before injection medication
question
Which needle is best for a 2.5 mL IM injection? A. 10mL B. TB syringe C. 3 mL D. insulin syringe
answer
C. 3mL
question
What should you do if you don't have enough medication in syringe while withdrawing from an ampule and expelling air/excess medication? A. Note in record this happened in record after you give injection B. Open another ampule and fill syringe to prescribed dose C. Start over b/c each batch of medication is different D. Use 2 different syringes for each ampule
answer
C. Start over b/c each batch of medication is different
question
You're preparing an injection from a liquid vial. You have the MAR what else do you need? (SATA) A. syringe B. needle for withdrawal C. needle for injection D. filter needle E. alcohol swabs F. diluent
answer
A. syringe B. needle for withdrawal C. needle for injection E. alcohol swabs
question
What should you do if dry medication requires reconstitution doesn't go into solution (clumping)? A. assume its a bad dose and mix new vial B. mix until all dry medication is mixed into the solution C. contact pharmacist and ask advice D. add more diluent
answer
B. mix until all dry medication is mixed into the solution
question
What should a nurse do first when drawing up a 10 unit of Humulin R (regular) insulin and 30 units of Humulin N (NPH) insulin in same syringe? A. inject 30 U of air into Humulin N insulin B. inject 10 U of air into Humulin R insulin C. draw 10 U of Humulin R D. draw 30 U of Humulin N
answer
A. inject 30 U of air into Humulin N insulin
question
When you're teaching a pt how to prepare mixed insulin what is a key thing to remember about the procedures (ie the order to draw)
answer
ALWAYS draw regular insulin first then modified insulin (N R R N)
question
John is a new nursing tech who also happens to be a diabetic. He says he knows how to prepare insulin injections and offers to help you prepare insulin injections for a diabetic pt on the floor. Which of the following are correct responses to John? (SATA) A. licensing guidelines only allow nurses to prepare injections B. Allow him to prepare the insulin as long as he can verbalize the proper steps C. Let him prepare the insulin D. you review side effects of insulin w/ John and ask him to report to you immediately if he observes any of thoses signs
answer
A. licensing guidelines only allow nurses to prepare injections D. you review side effects of insulin w/ John and ask him to report to you immediately if he observes any of thoses signs
question
What should you do if a pt develops s/s of an allergy or has adverse side effects to a medication?
answer
- assess pt - document and add allergy to chart - call provider
question
What are some symptoms you would expect from a pt who experiences hypoglycemia after insulin?
answer
confusion, blurred vision, cold sweats, shaking
question
Where is the best injection site for blood thinners?
answer
abdomen - because it allows the medication to be released into the the system at a steady rate
question
Which site is least desirable for 3 mL IM injections? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus Lateralis
answer
Deltoid
question
What precautions do you take to minimize risk of IM medication entering blood vessel? A. aspirate before injecting meds B. use longer needle C. apply pressure to injection site for 60 seconds after needle withdrawal D. carefully inspect injection site for signs of bruising
answer
A. aspirate before injecting meds
question
A nurse is preparing an IV infusion prior to initiating an IV. The nurse removes the protective sheath covering the tubing insertion spike and accidentally touches the spike. What is the nurse's next action?
answer
discard the IV tubing and obtain new ones
question
The nurse knows to monitor the pts IV site for signs of phlebitis. Why is it important to discontinue the IV site if phlebitis is evident? A. because it causes the pt pain B. to prevent the spread of infection to other extremities C. phlebitis will eventually result in infiltration D. phlebitis can be dangerous because blood clots can occur
answer
D. phlebitis can be dangerous because blood clots can occur
question
The nurse notices failure of flow in drip chamber with roller clamp open and an absence of swelling at insertion site. What should you do? (SATA) A. forceful flushing to achieve catheter patency without relocating IV site B. should determine patency by aspirating for blood C. should inject heparin flush solution into nearest port D. should apply a warm pack to IV site E. check for kink in IV line
answer
B. should determine patency by aspirating for blood E. check for kink in IV line
question
Which of the following would be consistent with infiltration (SATA)? A. cool to the touch B. swelling around site C. warm to the touch D. with or without pain E. redness
answer
A. cool to the touch B. swelling around site D. with or without pain
question
Client comes into the clinic for an ID skin test. What questions should you ask the pt? (SATA) A. have you ever had a tb skin test in the past? B. will you be able to return to the clinic in 72 hrs for the test results to be read? C. what medications are you taking? including OTC D. do you have any scars/tattoos on your abdomen? E. are you right or left handed?
answer
A. have you ever had a tb skin test in the past? B. will you be able to return to the clinic in 72 hrs for the test results to be read? C. what medications are you taking? including OTC E. are you right or left handed?
question
What should you do if you insert the angle of the needle of ID too deep?
answer
withdraw needle, change needle, and try in new area
question
Which technique is most accurate in identifying an appropriate vein site for IV catheter insertion into the arm? A. Remove any clothing that is covering the arm. B. Apply a warm washcloth to the arm at the proposed site. C. Elevate the selected arm on a pillow for 2 to 3 minutes. D. Apply a tourniquet to the selected arm 4 to 6 inches above the proposed site.
answer
D. Apply a tourniquet to the selected arm 4 to 6 inches above
question
When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure? A. Assess the patient's understanding of the placement of the device. B. Insert the access device as quickly as possible. C. Ask the patient to select the arm preferred for access. D. Apply a topical anesthetic to the area before inserting the device.
answer
A. Assess the patient's understanding of the placement of the device.
question
Which action minimizes the patient's risk for injury when inserting a venous access device into the arm? A. Wearing clean gloves during the procedure B. Using a larger vein found on the palmar (ventral) side of the wrist C. Checking for a radial pulse once the tourniquet has been applied D. Priming the extension tubing after attaching it to the newly placed venous access device
answer
C. Checking for a radial pulse once the tourniquet has been applied
question
The nurse is preparing to insert a venous access device into a newly admitted 75-year-old patient. Which vein is not an inappropriate choice for IV insertion in this patient? A. Basilic vein B. Cephalic vein C. Superficial dorsal vein D. Median cubital vein
answer
C. Superficial dorsal vein
question
The nurse is using chlorhexidine to prepare the site before inserting a venous access device into the median cubital vein of a 60-year-old patient. Which action is correct? A. Wash the site with soap and water. B. Allow the site to dry 1 to 2 minutes after cleansing it with chlorhexidine. C. Cleanse the site using a circular motion, starting at the insertion site and working outward. D. Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.
answer
D. Cleanse the area by first swabbing horizontally, then vertically with the applicator for about 30 seconds.
question
Which action would the nurse perform to best ensure effective insertion of a venous access device into a patient's arm? A. Anchor the vein by placing a thumb 1 to 2 inches below the site. B. Insert the device tip at a 45-degree angle distal to the proposed site. C. Place the patient's left arm in a dependent position for 5 minutes before assessment. D. Apply a tourniquet to the left antecubital fossa 8 to 12 inches above the proposed site.
answer
A. Anchor the vein by placing a thumb 1 to 2 inches below the site.
question
How might the nurse prepare a patient to anticipate some discomfort when inserting a venous access device? A. Instruct the patient to expect a sharp, quick stick. B. Insert the access device as quickly as possible. C. Apply a topical anesthetic to the area before inserting the device. D. Promise that the procedure will not hurt once the device has been inserted.
answer
A. Instruct the patient to expect a sharp, quick stick.
question
Which of the following technique(s) is/are best for minimizing a patient's risk for injury when inserting a venous access device? A. Inserting the needle with the bevel up B. Using a vein on the dorsal surface of the arm C. Holding the skin taut directly below the site D. All of the above
answer
D. All of the above
question
The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return? A. Loosen or remove the tourniquet. B. Advance the catheter 1 inch into the vein. C. Lower the catheter until it is flush with the skin. D. Thread the catheter into the vein up to the hub.
answer
C. Lower the catheter until it is flush with the skin.
question
Which instruction might the nurse give to NAP regarding the care of a patient with an intravenous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 milliliters." D. "Explain the symptoms of infection to the patient."
answer
C. "Let me know when you notice that the IV bag contains less than 100 milliliters."
question
Why is it important to label the gauze dressing covering the site of an intravenous access device with the date, time, and nurse's initials? A. Reminds the nurse to document the insertion of the device B. Proves that the access site was assessed C. Informs the nurse and other staff when the next dressing change is due D. Reminds the nurse when to change the infusion tubing
answer
C. Informs the nurse and other staff when the next dressing change is due
question
Which action will the nurse take to minimize a patient's risk for injury when applying a dressing to an infusion site? A. Use aseptic technique throughout the process. B. Apply a skin protectant to the skin before the intervention. C. Apply a transparent dressing that allows for visualization of the site. D. Explain the process to the patient before implementation.
answer
A. Use aseptic technique throughout the process.
question
The NAP reports to the nurse that a patient's intravenous access device dressing is wet. What would the nurse do first? A. Assess the site. B. Instruct the NAP on how to change the dressing. C. Remove the device, and insert a new one. D. Reinforce the dressing with more gauze.
answer
A. Assess the site.
question
When applying a dressing to an infusion site on a patient's left forearm, what will the nurse do to ensure proper maintenance of the tubing? A. Apply a transparent dressing to the insertion site. B. Use a catheter stabilizing device when applying the dressing. C. Apply the dressing proximal to the tubing and catheter hub connector. D. Secure the tubing to the patient's dressing with 1-inch tape.
answer
C. Apply the dressing proximal to the tubing and catheter hub connector.
question
Which action will the nurse take to minimize a patient's risk for injury when applying a gauze dressing to an infusion site? A. Avoid encircling the arm with tape B. Not secure the tubing and catheter hub with tape C. Secure the tubing in two different locations on the arm D. Label the dressing with the date and time of application
answer
A. Avoid encircling the arm with tape
question
The nurse consistently observes that the positioning of a confused patient's arm has a direct effect on the flow rate of the IV solution. What might the nurse do to ensure infusion of the patient's IV fluid at a consistent rate? A. Restart the IV in another location less affected by the patient's positioning. B. Include this information in the shift report regarding this patient. C. Assess the flow rate every 1 to 2 hours. D. Instruct the patient to avoid positioning the arm in ways that alter the flow rate of the solution.
answer
A. Restart the IV in another location less affected by the patient's positioning.
question
Which instruction might the nurse give to NAP regarding the care of a patient with a venous access device? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know if you notice that the dressing has become damp." D. "Make sure the patient knows to notify me if the IV site becomes painful, swollen, or red."
answer
C. "Let me know if you notice that the dressing has become damp."
question
What might the nurse do to minimize the risk for injury in a patient receiving IV therapy? A. Regulate the flow rate of the infusion. B. Assess the patient frequently for pain at the IV site. C. Monitor the IV site frequently for signs of infiltration and phlebitis. D. Educate the patient regarding symptoms of infiltration and phlebitis.
answer
A. Regulate the flow rate of the infusion.
question
What would the nurse do to assess a patient's risk for embolus when removing a venous access device? A. Inspect the site for redness. B. Visualize the tip of the IV device. C. Palpate the site for possible edema. D. Ask the patient to rate any pain at the site.
answer
B. Visualize the tip of the IV device.
question
Which instruction might the nurse give to NAP when caring for a patient whose IV access device is to be removed? A. "Remember to wear gloves to minimize the risk for infection." B. "Be sure to keep pressure on the site for at least 2 to 3 minutes." C. "Let me know if you notice any bleeding on the site dressing." D. "Make sure the patient knows to notify me if the IV site becomes painful."
answer
C. "Let me know if you notice any bleeding on the site dressing."
question
What might the nurse do to improve a patient's cooperation during the removal of an IV access device? A. Describe the entire procedure to the patient. B. Assure the patient that you will remove the IV catheter quickly. C. Assure the patient that the procedure will take only about 5 minutes. D. Tell the patient that the procedure will cause only a slight burning sensation.
answer
A. Describe the entire procedure to the patient.
question
Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm? A. Keep the hub parallel to the skin. B. Cleanse the site with an antibacterial swab. C. Cut the dressing to facilitate its removal. D. Turn the IV tubing roller clamp to the "off" position.
answer
A. Keep the hub parallel to the skin
question
What will the nurse do to prevent possible complications after removing an IV access device in a patient on anticoagulant therapy? A. Instruct the patient to report immediately any sign of bleeding on the site dressing. B. Perform hand hygiene and wear clean gloves while removing the device. C. Encourage the patient to keep a cold compress on the site for 15 minutes. D. Apply firm pressure to the site with sterile gauze for 10 minutes.
answer
D. Apply firm pressure to the site with sterile gauze for 10 minutes.
question
Which instruction to NAP reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving IV fluids by gravity drip? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "Let me know when you notice that the IV bag contains less than 100 mL." D. "Tell the patient to notify me if the IV site is painful, swollen, or red."
answer
C. "Let me know when you notice that the IV bag contains less than 100 mL."
question
The provider has ordered that a patient be given 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion? A. Calculate the hourly volume of normal saline the patient should receive. B. Determine the drop factor of the tubing that will be used for the infusion. C. Calculate the drops per minute at which the tubing will be regulated. D. Determine the drops per mL that the tubing will deliver.
answer
A. Calculate the hourly volume of normal saline the patient should receive.
question
The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute? A. 25 drops/minute B. 30 drops/minute C. 35 drops/minute D. 40 drops/minute
answer
A. 25 drops/minute
question
The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order? A. Infusing D5W 1000 mL for 8 hours and then discontinuing the infusion B. Infusing D5W at a rate of 125 mL/hour for 24 hours and then discontinuing the infusion C. Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order D. Calling the health care provider to clarify the order
answer
C. Infusing D5W at a rate of 125 mL/hour until the health care provider changes the order
question
Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children? A. Using microdrip tubing for the infusion B. Using macrodrip tubing for the infusion C. Using a volume-control device for the infusion D. Not infusing more than 25 mL/hour of IV fluids
answer
C. Using a volume-control device for the infusion
question
Which response might the nurse give to NAP who reports that the alarm is sounding on a patient's electronic infusion device? A. "Assess the IV site for signs of inflammation." B. "Be sure to change the dressing on the IV site." C. "I'll check the IV site and pump." D. "Turn off the alarm."
answer
C. "I'll check the IV site and pump."
question
How would the infusion of IV fluids be affected if the tubing were unintentionally dislodged from the chamber of the control mechanism of the electronic infusion device (EID)? A. The infusion would slow to a "keep vein open" rate. B. The patient would receive a bolus of fluid. C. The infusion would continue at the prescribed rate. D. The flow of fluid would stop.
answer
D. The flow of fluid would stop.
question
A patient is prescribed 1000 mL of IV normal saline to run over 8 hours. The initial fluid is hung at 0800. How many milliliters of fluid will have infused by 1200? A. 125 mL B. 250 mL C. 500 mL D. 625 mL
answer
C. 500 mL
question
The nurse calculates that the patient is to receive 125 mL of IV normal saline per hour. After programming the infusion pump to deliver at that rate, how would the nurse ensure accurate fluid administration? A. First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour. B. Ask another nurse to assess the programming of the pump. C. Set the pump alarm to sound when half of the fluid has infused. D. Check the IV site for complications.
answer
A. First verify that the fluid is dripping, and then check the level of fluid remaining in the container every hour.
question
Which information is not necessary for the nurse to include when documenting the use of an electronic infusion device (EID) for an intravenous infusion? A. Location of the insertion site B. Time at which the infusion began C. Patient's pulse and heart rate D. Hourly volume flow rate of the infusion
answer
C. Patient's pulse and heart rate
question
After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How would the nurse remove them? A. Begin the process again. B. Add more fluid to the drip chamber. C. Inject a syringe of saline into the tubing to vent the air bubbles. D. Close the clamp, stretch the tubing downward, and flick the tubing.
answer
D. Close the clamp, stretch the tubing downward, and flick the tubing.
question
Which action can the nurse take to minimize the patient's risk for infection when applying new tubing to a primary IV infusion? A. Using aseptic technique throughout the process B. Changing the tubing each shift C. Changing the tubing at the same time a new primary fluid bag is hung when possible D. Both selections A and C are appropriate to minimize the patient's risk for infection
answer
D. Both selections A and C are appropriate to minimize the patient's risk for infection
question
While changing a patient's hospital gown, the extension set on the IV infusion becomes disconnected and ends up on the bed linens. What would the nurse do? A. Reconnect the extension set. B. Clean the end with an alcohol swab, and reconnect it. C. Pull the IV from the site, and insert a new catheter. D. Change the extension set tubing.
answer
D. Change the extension set tubing.
question
What would the nurse do to ensure the correct administration of gravity drip IV fluid after changing the tubing on a patient's primary infusion? A. Change the tubing with each new infusion bag. B. Wear clean treatment gloves when changing the tubing. C. Recheck the drip rate by counting the drops for 1 full minute. D. Assess the condition of the patient's insertion site for possible infiltration.
answer
C. Recheck the drip rate by counting the drops for 1 full minute
question
Which instruction would the nurse give to NAP when caring for a patient who is receiving IV fluids? A. "If the IV tubing gets disconnected, quickly reconnect it for me and let me know." B. "It's okay for you to turn off the pump alarm when it beeps." C. "Let me know when the IV bag is almost empty." D. "Please check the IV site for me, and let me know if it's tender."
answer
C. "Let me know when the IV bag is almost empty."
question
Which instruction might the nurse give to NAP regarding the care of a patient with an IV site dressing? A. "Assess the IV site frequently for signs of inflammation." B. "Be sure not to obscure the insertion site with the dressing." C. "If the gauze dressing looks damp, replace it with a dry 4 x 4 gauze." D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."
answer
D. "Be sure to notify me if the patient reports that the IV site is painful or swollen."
question
How will the nurse minimize the risk for infection when changing a patient's IV catheter site dressing? A. Use aseptic technique throughout the process. B. Pull the tape toward the insertion site. C. Remove both the gauze dressing and the tape one layer at a time. D. Explain the process to the patient.
answer
A. Use aseptic technique throughout the process.
question
The nurse is concerned that a confused patient's erratic movements may compromise the IV insertion site. Which action can the nurse take to protect the patient and the site from injury? A. Apply an IV site-protection device over the site, such as House UltraDressing. B. Apply restraints to the patient. C. Check the patient frequently. D. Instruct the patient to avoid dislodging the IV catheter.
answer
A. Apply an IV site-protection device over the site, such as House UltraDressing.
question
Which action would the nurse take if an IV insertion site appeared red, warm, and swollen? A. Assess for blood return. B. Discontinue the infusion. C. Change the existing dressing. D. Secure the tubing with more tape.
answer
B. Discontinue the infusion.
question
How can the nurse ensure that a patient's IV tubing will not tug on the infusion catheter after a transparent dressing is applied to an infusion site on the arm? A. Encircle the arm with tape. B. Secure the tubing and catheter hub with tape. C. Secure the tubing in two different locations on the arm. D. Label the dressing with the date and time of application.
answer
C. Secure the tubing in two different locations on the arm.
question
Which instruction reflects the nurse's correct understanding of the role of NAP in caring for a patient receiving an IV antibiotic medication by piggyback? A. "Assess the IV site frequently for signs of infiltration." B. "Let me know immediately if the patient complains of pain at the IV site." C. "Notify the physician that the patient is allergic to the medication prescribed." D. "Remember to hang the piggyback medication higher than the primary solution."
answer
B. "Let me know immediately if the patient complains of pain at the IV site."
question
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? A. Use an infusion pump to regulate the flow rate of the piggyback medication. B. Hang the piggyback medication higher than the primary fluid. C. Attach the piggyback medication to the most proximal insertion port on the primary tubing. D. Use a secondary infusion set for the piggyback tubing.
answer
B. Hang the piggyback medication higher than the primary fluid.
question
What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? A. Use a site into which a primary solution is already infusing. B. Assess the IV site before initiating the IV piggyback medication. C. Select a relatively small vein to infuse the IV medication. D. Instruct NAP to notify you immediately if the insertion site appears swollen.
answer
B. Assess the IV site before initiating the IV piggyback medication.
question
What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? A. Remove the tubing from the primary line Y-site port, and cap the end. B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. C. Place an unopened secondary setup at the bedside, and discard the used one. D. Change both the primary and secondary tubing upon terminating the piggyback infusion.
answer
B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose.
question
Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? A. Use the most proximal insertion port on the primary tubing. B. Hang the piggyback solution higher than the primary infusion solution. C. Use a pump to regulate the infusion rate of the piggyback medication. D. Flush the saline lock with sodium chloride solution before initiating the infusion.
answer
D. Flush the saline lock with sodium chloride solution before initiating the infusion.
question
Which task might the nurse delegate to NAP caring for a patient receiving IV medication via mini-infusion pump? A. Assessing the IV site frequently for signs of infiltration B. Notifying the nurse if the pump alarm sounds C. Informing the physician that the patient is allergic to the prescribed medication D. Ensuring that the medications being delivered intravenously are compatible
answer
B. Notifying the nurse if the pump alarm sounds
question
Which action by the nurse would reduce his or her exposure to blood borne pathogens while administering fluids to a patient by mini-infusion pump? A. Cleaning the injection port with an antiseptic swab B. Applying clean gloves C. Recapping the end of the mini-infusion tubing after use D. Performing hand hygiene prior to administration
answer
B. Applying clean gloves
question
Which step to protect the patient from infection is of special concern when preparing a mini-infusion pump to deliver an analgesic? A. Ensure that the syringe is secure within the mini-infusion pump. B. Identify any history of allergic reaction to the prescribed analgesic. C. Use an antiseptic swab to wipe the proximal injection port on the primary tubing. D. Carefully depress the syringe plunger to fill the tubing with medication.
answer
C. Use an antiseptic swab to wipe the proximal injection port on the primary tubing.
question
What is the most important nursing intervention to ensure the patient's safety when initiating infusion of an analgesic by mini-infusion pump? A. Checking the flow rate of the primary infusion B. Staying with the patient during the first few minutes of the infusion C. Explaining the purpose of the medication to the patient D. Documenting the patient's expected response to the analgesic
answer
B. Staying with the patient during the first few minutes of the infusion
question
What can the nurse do to help protect the patient from infiltration of IV medication? A. Use the most proximal insertion port on the existing primary tubing. B. Ensure that the syringe has been securely loaded into the mini-infusion pump. C. Set the pump to deliver the medication over the prescribed time period. D. Check the IV site for placement before and after the infusion.
answer
D. Check the IV site for placement before and after the infusion.
question
Which statement might a nurse make to NAP when caring for a patient prescribed an IV bolus of analgesic medication? A. "Assess the IV site frequently for signs of inflammation." B. "Let me know immediately if the patient complains of pain at the insertion site." C. "Make sure the patient knows what results to expect from the medication." D. "Observe the IV site for sudden swelling when the IV bolus is administered."
answer
B. "Let me know immediately if the patient complains of pain at the insertion site."
question
Which patient safety issue is specific to administration of medication by IV bolus? A. Determining that the medication is compatible with the IV solution B. Checking for patient allergies before giving the medication C. Identifying the patient using two identifiers D. Checking the medication against the medication administration record (MAR) three times
answer
A. Determining that the medication is compatible with the IV solution
question
What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? A. Injecting the medication at the prescribed rate B. Observing the insertion site after giving the medication C. Instructing the patient about side effects to report to the nurse D. Using an alcohol swab to wipe the insertion port on the primary tubing
answer
A. Injecting the medication at the prescribed rate
question
How can the nurse best minimize the patient's risk for infection when administering an IV bolus of an analgesic? A. Use the injection port closest to the patient. B. Assess the IV insertion site for signs of infiltration. C. Follow aseptic technique during the entire process. D. Instruct the patient to report any adverse medication reactions.
answer
C. Follow aseptic technique during the entire process.
question
If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? A. Attempt to aspirate the site again. B. Prepare to access another IV site. C. Assess the saline lock site for signs of phlebitis. D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.
answer
D. Assess the site for swelling or coolness while flushing the saline lock with normal saline.
question
The nurse is preparing to instill eardrops for the treatment of an ear infection. To best minimize the risk of injury to the patient as a result of the instillation, the nurse should: A. Warm the eardrops to room temperature before instillation. B. Wear treatment gloves during the entire application process. C. Introduce the medication with the patient in a sitting position. D. Use a cotton-tipped applicator to remove any visible cerumen
answer
A. Warm the eardrops to room temperature before instillation.
question
The nurse is preparing to instill antibiotic eardrops in a patient who will be discharged with a prescription for the medication. The following information should be included in the patient's education plan to best ensure maximum therapeutic response when self-applying the medication: A. Remain in the lateral position for at least 5 minutes after instillation. B. Bring refrigerated ear medication to room temperature before instillation. C. Place a cotton ball firmly into the ear canal for 30 minutes after instillation. D. Apply a warm, damp washcloth to the pinna to remove any crusted discharge.
answer
A. Remain in the lateral position for at least 5 minutes after instillation.
question
The nurse is preparing to discharge a patient after providing instructions regarding the self administration of an antibiotic ear medication. The nurse should assess the patient specifically for the ability to: A. Understand the purpose of the medication. B. Appropriately handle the medication applicator. C. Read the instructions provided with the medication. D. Identify the signs of an allergic medication reaction.
answer
B. Appropriately handle the medication applicator.
question
The nurse is instilling a medication into the ear of an elderly patient with an ear infection. To best maximize the distribution of the medication after instillation, the nurse should instruct the patient to: A. Have a family member instill the medication. B. Avoid contaminating the medication's applicator tip. C. Instill the medication at the time the physician ordered. D. Instill the medication after gently pulling the ear up and back.
answer
D. Instill the medication after gently pulling the ear up and back.
question
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the instillation of eye medications? A. "Did you let the eye medication warm to room temperature?" B. "Do you think the patient is capable of instilling his own eye drops?" C. "Be sure to slightly hyperextend her neck when instilling the medication." D. "Her vision may be temporarily impaired, so please help her to the bathroom."
answer
D. "Her vision may be temporarily impaired, so please help her to the bathroom."
question
The nurse is administering a time-released capsule to a patient with a history of dysphagia after a cerebral vascular accident. To minimize the risk of injury to the patient, the nurse should: A. Encourage the patient to drink plenty of water when swallowing the capsule. B. Open the capsule and place the contents into 3 ounces of juice. C. Place the capsule in a spoonful of the patient's applesauce. D. Save the capsule to be administered last.
answer
C. Place the capsule in a spoonful of the patient's applesauce.
question
The nurse is preparing to administer several oral medications when the patient states, I'd really like to take these pills with orange juice. The most appropriate response to this request is for the nurse to: A. Determine whether the patient's prescribed diet includes orange juice. B. Establish whether the medications may be taken with orange juice. C. Ask the dietary aide to order extra orange juice for the unit. D. Provide the patient with the requested orange juice.
answer
B. Establish whether the medications may be taken with orange juice.
question
The nurse has provided a patient with a prn oral analgesic that may be repeated as needed every 6 to 8 hours. The most appropriate follow-up action to ensure appropriate pain management is to: A. Re-assess the patient's pain in 30 to 40 minutes. B. Document the patient's request for pain medication. C. Provide the patient with the pain medication again in 6 hours. D. Include the patient's pain history in the end-of-shift nursing report.
answer
A. Re-assess the patient's pain in 30 to 40 minutes.
question
The patient who has a history of nighttime confusion is to receive several oral medications at bedtime. To best ensure that the patient has swallowed the medication, the nurse should: A. Administer each tablet to the patient individually. B. Observe the patient closely as he swallows the tablets. C. Ask the patient to open his mouth after swallowing the tablets. D. Provide the patient with a full glass of water to swallow with the tablets.
answer
C. Ask the patient to open his mouth after swallowing the tablets.
question
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the application of topical medications? A. Let me know when it's time to change the patient's analgesic patch. B. Please apply that moisturizing lotion to the patient's elbows. C. How well did the nicotine patch help the patient's cravings? D. Did you flush the nicotine patch when you removed it?
answer
B. Please apply that moisturizing lotion to the patient's elbows.
question
The nurse is preparing to discharge a patient after providing instructions regarding the self administration of a topical medication. The nurse should best follow up this intervention before discharge by: A. Identifying the most common application errors for the patient. B. Reviewing the material with the patient and caregiver. C. Evaluating the patient's ability to apply the medication. D. Providing the patient with printed materials for referral.
answer
C. Evaluating the patient's ability to apply the medication.
question
Which of the following statements made by a nurse is most reflective of the proper understanding of the role that unlicensed ancillary staff may play regarding the insertion of a rectal suppository? A. Do you think the patient is capable of inserting the suppository? B. Please tell her to report any rectal bleeding she may have. C. Be sure to let me know if she reports any rectal pain. D. Did you remember to lubricate the suppository?
answer
C. Be sure to let me know if she reports any rectal pain.
question
The nurse has medicated a patient with a laxative in the form of a rectal suppository. Which of the following nursing actions best minimizes the patient's risk for injury as the medication produces the desired affect? A. Placing a bedpan within the patient's easy reach B. Ensuring that the path to the bathroom is free of clutter C. Providing the patient with extra-absorbent padding on the bed D. Instructing the patient to use the call bell for assistance to the bathroom
answer
D. Instructing the patient to use the call bell for assistance to the bathroom
question
The nurse should question an order to insert a suppository into the rectum of a patient experiencing: A. Watery diarrhea. B. Rectal inflammation. C. External hemorrhoids. D. Internal hemorrhoids.
answer
A. Watery diarrhea.
question
The nurse is preparing to administer a prescribed medication via the subcutaneous route. To best ensure patient safety, the nurse should: A. Perform appropriate hand hygiene. B. Observe the six rights of medication administration. C. Identify the patient in accordance with institutional policies. D. Confirm the prescription with the medication administration record (MAR).
answer
B. Observe the six rights of medication administration
question
To minimize the risk of skin irritation when delivering a medication via the subcutaneous route, the nurse realizes that: A. The needle should be at least 5/8 inch in length. B. The injection site should not be massaged after the injection. C. The amount of medication should not exceed 1 ml in volume. D. Only non-irritating medications can be administered via this route.
answer
C. The amount of medication should not exceed 1 ml in volume. - Book does say can go to 1.5mL but to 1 mL is better
question
When preparing to administer medication via the subcutaneous route, the nurse should avoid which of the following sites? A. Lower abdomen of an obese patient B. Scapular area of a patient who is on bedrest C. Right deltoid of a high school softball pitcher D. Lateral aspect of the thigh of a patient with a venous clot
answer
C. Right deltoid of a high school softball pitcher
question
To insure proper needle insertion, during the administration of heparin via the subcutaneous route to a patient whose body mass is above the normal range, the nurse should: A. Insert the needle at a 90-degree angle. B. Use a needle that is 3/8 inch in length. C. Avoid sites with an excess of subcutaneous tissue. D. Pinch up the skin at the site with your thumb and forefinger.
answer
D. Pinch up the skin at the site with your thumb and forefinger.
question
To best minimize the patient's risk of injury when delivering a medication via intramuscular injection, the nurse realizes that the: A. Patient should be instructed to relax the muscle at the insertion point. B. Needle should be quickly inserted into the muscle at a 90-degree angle. C. Plunger should be pulled back after the needle is inserted into the muscle. D. Skin over the insertion site should be held taut during the needle insertion.
answer
C. Plunger should be pulled back after the needle is inserted into the muscle.
question
When preparing to administer medication via the intramuscular route, the nurse should avoid which of the following sites? A. Ventrogluteal muscle of an obese patient B. Vastus lateralis muscle of a patient with a broken tibia C. Ventrogluteal muscle of a patient who is on bedrest D. Vastus lateralis muscle of a patient with burns to both thighs
answer
D. Vastus lateralis muscle of a patient with burns to both thighs
question
When preparing an injection of mixed insulin that includes 12 units of NPH and 5 Units of Regular insulin, the nurse initially confirms proper dosage when: A. 5 units of clear insulin are visible in the syringe. B. 12 units of cloudy insulin are visible in the syringe. C. Another registered nurse verifies the presences of 17 units of insulin. D. The prescription confirms the medication administration record (MAR).
answer
A. 5 units of clear insulin are visible in the syringe.
question
The nurse is preparing to withdraw medication for an opened multidose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, the nurse should: A. Put on clear treatment gloves. B. Vigorously shake the vial. C. Wipe the rubber seal of the vial with an alcohol swab. D. Introduce air equal to the amount of medication needed.
answer
C. Wipe the rubber seal of the vial with an alcohol swab.
question
When preparing an injection with medication contained in an ampule, the nurse can best minimize the risk of infection for the patient by: A. Preparing the medication for administration in the patient�s room. B. Donning treatment gloves during the preparing of the medication. C. Preserving the sterility of the needle during the preparation process.
answer
C. Preserving the sterility of the needle during the
question
The nurse is preparing to administer insulin to a patient. Which of the following actions will best ensure the patient's safety? A. Determining the patient's current blood glucose level B. Preparing the injection site with an antibacterial cleansing C. Donning treatment gloves when administrating the medication D. Wiping the seal of the vial with alcohol before withdrawing the medication
answer
A. Determining the patient's current blood glucose level
question
When preparing to administer an injection of insulin, the nurse recognizes that which of the following areas is not an appropriate injection site? A. Lateral aspect of either thigh B. Lateral aspect of either buttock C. Posterior aspect of the upper arm D. Area within 2 inches of the umbilicus
answer
D. Area within 2 inches of the umbilicus
