You
The primary care provider writes a medication order on the order sheet of the patient. The order that includes all the necessary information is:
a. 1/5/13 at 0900: warfarin (Coumadin) 1 mg p.o. qd A. Primary Care Provider
b. 1/5/13 Give warfarin 1 tab qd A. Primary Care Provider
c. 1/5/13 Coumadin 1 tab p.o. A. Primary Care Provider
d. 0900 Give warfarin (Coumadin) 1 mg p.o. A. Primary Care Provider
A
A complete medication order includes the full name of the medication, the dose to be given, the route of administration, how often the medication is to be given, and the date and time written, as well as the prescriber’s signature.
he nurse is to administer a dissolved medication via feeding tube. After donning gloves and attaching the irrigation syringe to the tube, the nurse should next:
a. instill the medication into the syringe slowly.
b. draw the medication into the syringe and gently push into the tube.
c. flush the tubing with 15 to 30 mL of tap water and add the medication just as the water is about to finish.
d. flush the tubing with 15 to 30 mL of sterile water and add the medication just as the water is about to finish.
C
The nurse should flush the tubing with tap water and add the medication as the water is about to finish. Administration of medication into the feeding tube should be done by gravity instillation, and pressure should be applied gently only if needed to initiate flow.
The nurse checking the MAR or eMAR finds that an order for an antibiotic is now 8 days old. The nurse should:
a. check the medications, performing three medication checks.
b. give the ordered medication.
c. contact the primary care provider for a new order.
d. give the medication, then notify the primary care provider.
C
The nurse contacts the primary care provider for a new order. Antibiotic orders generally have a 5- to 7-day limit before they need to be renewed.
When administering several medications via feeding tube, the nurse should:
a. dilute each medication with at least 40 mL of water.
b. mix each medication individually.
c. mix all medications together to facilitate administration.
d. use sterile gloves for the procedure.
B
Medications should be mixed separately to prevent clumping.
To ensure the proper administration of a tuberculin test, the nurse will:
a. use a 3 mL syringe.
b. choose a 21 gauge, 1 inch needle.
c. insert the needle at a 30-degree angle.
d. inject slowly to form a bleb.
D
An intradermal injection should be done using a 1 mL syringe with a 25, 27, or 29 gauge needle that is 5/8 inch long. The needle is inserted at a 15 degree angle, and medication is injected slowly to form a bump or a bleb underneath the skin.
The best angle to insert the needle when administering a subcutaneous injection is at an angle of:
a. 45 to 90 degrees.
b. 30 to 45 degrees.
c. 15 to 30 degrees.
d. 5 to 15 degrees.
A
The needle is inserted at a 45- or 90-degree angle depending on the needle length and the size of the patient.
The nurse computes the dose of medication as 2.4 million units of penicillin to be delivered in 4 mL. The nurse should:
a. give the 4 mL using a 5 mL syringe.
b. inform the charge nurse that the dose is too large to be given IM.
c. divide the dose into two 3 mL syringes and give as a divided dose.
d. ask the primary care provider if another medication can be used.
C
The maximum number of milliliters that can be injected into the ventrogluteal muscle is 3 mL. If the person has small muscle mass, or if the dose exceeds 3 mL, the dose should be divided into two doses.
A nurse has just administered a medication to a patient using a syringe that is not a safety syringe. To dispose of the needle and syringe safely, the nurse should:
a. recap the needle and dispose of it in the trash receptacle.
b. recap the needle and dispose of it in the sharps container.
c. leave the needle uncapped and dispose of it in the trash receptacle.
d. leave the needle uncapped and dispose of it in the sharps container.
D
Needles are not to be recapped and should be deposited in the sharps container.
When the nurse is preparing to draw medication from an ampule, the proper procedure is to:
a. allow medication to float freely in the body, neck, and stem.
b. wrap the neck with a gauze or alcohol sponge to the open ampule.
c. break the ampule so that it opens toward her.
d. inject air into the ampule to ease the withdrawal of the medication.
B
The medication should rest in the body of the ampule before being withdrawn, and the neck should be wrapped to protect the nurse from glass cuts when the ampule is snapped open.
A patient has an order to receive two intramuscular injections in the same syringe. The nurse should initially:
a. determine if the two medications are compatible in the same syringe.
b. obtain a larger syringe that will accommodate both medications.
c. select two syringes to give the medications separately.
d. ask the patient whether he would prefer one or two injections.
A
The first step is to determine whether the two medications are compatible in the same syringe.
A patient has an order to receive a mixture of short- and long-acting insulin. The first step to properly draw them up in the same syringe is to:
a. shake both vials vigorously before use.
b. inject air into the short acting clear insulin.
c. withdraw the short acting clear insulin.
d. inject air into the long acting cloudy insulin.
D
The vials should be rolled gently to mix the insulin suspension evenly, but they should not be shaken. Air is injected first into the long acting cloudy insulin vial and then into the short acting clear insulin vial.
The nurse has an order to administer a TST (Tuberculin Skin Test) injection by the intradermal route. The maximum amount of medication that can be given using this route is:
a. 0.1 mL.
b. 0.75 mL.
c. 0.5 mL.
d. 0.2 mL.
A
The maximum dose that can be given via the intradermal route is 0.1 mL.
A nurse has administered a Tuberculin skin test to a patient in the outpatient clinic at 9:00 AM on Monday. The patient should be scheduled to return to the clinic to have the result read:
a. late Monday afternoon.
b. late Tuesday afternoon.
c. any time on Wednesday.
d. any time on Friday.
C
The results of the Tuberculin skin test should be read within 48 to 72 hours after injection.
A hospitalized patient has an order for subcutaneous heparin. The best location to administer this medication is the:
a. upper arm.
b. anterior thigh.
c. buttock.
d. abdomen.
D
The optimal site for heparin injection is the abdomen, because this area is not involved in muscular activity, as are the arms, buttocks, and legs.
When administering an intramuscular injection to an adult patient using the ventrogluteal site, the nurse should use which landmark to locate the area for injection?
a. The lower end of the trochanter and the knee
b. The upper end of the trochanter and the knee
c. The head of the trochanter and the posterior iliac spine
d. The head of the trochanter and the anterior iliac spine
D
The head of the trochanter and the anterior iliac spine are the landmarks used to give an injection in the ventrogluteal site. The ventrogluteal site is the safest in regard to possible injury to the patient’s sciatic nerve.
When administering an intramuscular injection for a 4-year-old child, the best site to use is the:
a. gluteus medius.
b. vastus lateralis.
c. ventrogluteal.
d. dorsogluteal.
B
The vastus lateralis is the best choice for children younger than 5 years old, because the gluteal muscle is not well developed.
A patient has a medication order for iron dextran (Imferon) to be given using the Z-track technique. The rationale for using this method is to:
a. avoid medication irritation.
b. avoid tissue scarring.
c. cause less painful method.
d. protect the sciatic nerve.
A
Z-track technique should be used with injection of this medication, because it creates a slanted needle track and avoids seepage of the medication back into subcutaneous or skin layers.
A patient asks why the clinic nurse asked him to remain in the clinic for 30 minutes after the injection of penicillin. The nurse explains that it is part of the standards of care to monitor for:
a. any pain reaction.
b. bleeding at the site.
c. infection at the site.
d. any allergic reaction.
D
The nurse should plan to monitor this patient for allergic response for 30 minutes after giving the first dose of a medication.
When administering heparin, the nurse will avoid:
a. using the lower abdomen as an injection site.
b. rotating sites.
c. massaging area for more than 3 seconds.
d. aspirating before injection.
D
The nurse should not aspirate before the insertion of heparin because evidence does not support this practice.
The nurse anticipates that the malnourished postoperative 70-year-old patient will receive an intravenous (IV) infusion of 5% dextrose in 0.45% saline, because it is:
a. isotonic.
b. hypotonic.
c. hypertonic.
d. total parenteral nutrition.
C
5% Dextrose in 0.45% saline is a hypertonic or high molecular solution and is a frequent choice for postoperative maintenance fluid.
The nurse is planning for the initiation of a blood transfusion. The type of tubing the nurse will prepare is a:
a. piggyback set.
b. primary infusion set.
c. controlled volume set.
d. Y administration set.
D
A Y administration set is used to place the blood on one side and normal saline on the other. This is necessary so that the blood can be discontinued but the vein can remain open with the saline in the case of a transfusion reaction or other medically necessary situation.
A patient rings the call bell and states that the IV insertion site is painful. The site is reddened, warm, and swollen. The nurse assesses that the patient is most likely experiencing:
a. bloodstream infection.
b. catheter embolus.
c. infiltration of the line.
d. phlebitis.
D
Phlebitis is caused by irritation of the vessel by the needle, cannula, medications, or additives to IV solution. Typical signs are erythema, warmth, swelling, and tenderness.
A patient receiving TPN fluid therapy experiences an air embolus in the central line. The nurse should immediately turn the patient onto the:
a. right side and raise the head of the bed.
b. right side and lower the head of the bed.
c. left side and raise the head of the bed.
d. left side and lower the head of the bed.
D
To anatomically minimize the risk of the air embolus reaching the lungs, the nurse should turn the patient onto the left side and lower the head of the bed. The primary care provider is notified immediately.
A nurse is monitoring the status of an older adult patient who is receiving IV therapy. Indicator of fluid volume overload is suspected when the nurse assesses:
a. crackles in the lung fields.
b. pulse rate of 64 beats/min, irregular.
c. respirations of 16 breaths/min, regular.
d. slight edema to the feet.
A
Fluid overload is signaled by crackles in the lung fields, increasing pulse rate, and shortness of breath.
A nurse accessing the injection port of the IV tubing will “scrub the hub” for:
a. 5 seconds.
b. 10 seconds.
c. 15 seconds.
d. 30 seconds.
C
The hub of the injection port on a piggyback setup should be scrubbed for 15 seconds.