Medication Administration
A nurse is administering an intravenous antibiotic to a patient. Which of the following data should the nurse recognize as the highest priority to prevent potential complications?
1) Identify the patient’s level of knowledge about the medication.
2) Identify if the patient has allergies to the medication.
3) Identify a specific site for the injection.
4) Identify the rationale for the patient receiving the medication.
2) Identify if the patient has allergies to the medication.
Which way can a nurse prevent injury from a needlestick?
1) Recap the needle before disposal.
2) Remove the needle from the syringe.
3) Immediately discard the needle and syringe in a puncture-proof container.
4) Stick it into the patient’s mattress until it can be disposed of.
3) Immediately discard the needle and syringe in a puncture-proof container.
Answer Rationale:
CO(2) Knowledge- Frazier p41 Rationale: We never recap needles nor do we stick needles into mattresses. The best method to avoid needle sticks is to place the syringe into a puncture-proof container.
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?
1) Chlorhexidine
2) Povidine-iodine
3) Soap and water
4) Alcohol-based antiseptic
3) Soap and water
Answer Rationale:
CO (3,4) Application-Frazier p. 34 Rationale: The CDC recommends washing hands with soap and warm water when in contact with spore-forming organisms, such as C. difficile. Proper hand washing includes using plenty of lather and friction for at least 20 seconds. The nurse should interlace her fingers, and rub her palms and the back of her hands with a circular motion at least five times each. She should keep her fingertips down to facilitate the removal of organisms.
All of the following are signs and symptoms of intravenous infiltration except:
1) Skin taught
2) Discomfort at the infusion site
3) Tissue remains cool to touch
4) Hemorrhage
4) Hemorrhage
Answer Rationale:
ANSWER: D CO 4, Knowledge, Frazier 87 RATIONALE: Signs and symptoms of infiltration: skin will feel tight and appear stretched and taut, increasing discomfort at the infusion site, slowing or sopping of the fluid infusion, tissue induration, swelling around the injection site with tissue remaining cool to touch
When using disinfectants, the nurse should take what precautions?
1) wear a gown
2) wear a mask
3) wear gloves
4) wear a cap
3) wear gloves
Answer Rationale:
Application, CO 3, Frazier p34 When using disinfectants the nurse should wear gloves and use splash protection equipment.
The nurse is preparing to administer a bolus medication. What should the nurse take into consideration?
1) which port to use
2) rate of administration
3) size syringe
4) size needle
2) rate of administration
All of the following are potential sites for contamination except:
1) Client’s skin microflora
2) Hands of medical personnel
3) Contaminated fluid
4) Sterile intravenous tubing
4) Sterile intravenous tubing
Answer Rationale:
CO(6) Knowledge-Frazier p35 Rationale: Potential sites for contamination of intravascular devices: client’s skin microflora, hands of medical personnel, hub colonization, contaminated fluid, contaminated on insertion, hematogenous
A nurse is reinforcing infection control practices for hand hygiene with a group of unit nurses. Which of the following information should the nurse reinforce in the teaching?
1) Change gloves between tasks on the same client.
2) Keep artificial nails trimmed short.
3) Use alcohol-based hand rubs before administering eye drops for a client.
4) Wash hands with alcohol-based hand rubs when caring for a client who has Clostridium difficile.
1) Change gloves between tasks on the same client.
Answer Rationale:
CO (2) Application Rationale: The nurse should include in the teaching to change gloves between tasks on the same client to prevent cross-contamination of microorganisms.
If an intravenous line has become infiltrated, the nurse will observe which assessment findings?
1) Pallor, pain
2) Erythema, warmth
3) Erythema, swelling
4) Warmth, swelling
3) Erythema, swelling
Answer Rationale:
CO(6) Knowledge-Frazier p87 Rationale: Infiltration of an IV site has an expected finding of swelling, cool to touch, and may have erythema.
How can you verify that you have entered the vein with the IV catheter?
1) You will be able to see the catheter through the skin
2) You learn through experience where the vein should be located
3) You observe a flashback of blood
4) You palpate with your non-dominant hand for the "pop" of the vein when the needle enters it
3) You observe a flashback of blood
A nurse is about to administer an intravenous medication directly into the vein. The nurse should understand that a disadvantage of parenterally administered medication is that they:
1) are irretrievable
2) have a slow onset
3) bypass the liver
4) have less bioavailability
1) are irretrievable
Answer Rationale:
CO (3) Application Rationale: Once a medication has been injected, it cannot be retrieved.
The doctor ordered 10 meq of potassium chloride intravenous for a patient. This is an example of which type of intravenous therapy?
1) maintenance
2) restorative
3) replacement
4) Keep open
2) restorative
Answer Rationale:
Application, CO 3, Frazier p84 Rationale- restorative therapy involves daily restoration of fluids and electrolytes. Laboratory testing is necessary to determine the amount of electrolytes and fluid lost and what is required to replace them.
The nurse cares for a patient admitted with sepsis. Which of the following are signs and symptoms of sepsis? Select all that apply.
1) fever
2) bradycardia
3) hypotension
4) increased white count
5) decreased respirations
1) fever
3) hypotension
4) increased white count
Answer Rationale:
Application, CO4, Frazier p89 Rationale- A patient with sepsis will experience chills, fever, tachycardia, increased respiration, and increased white count.
The nurse notes that the site of a client’s peripheral intravenous catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the intravenous catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?
1) Phlebitis of the vein
2) Infiltration of the intravenous line
3) Hypersensitivity to the intravenous solution
4) Allergic reaction to the intravenous catheter material
1) Phlebitis of the vein
Answer Rationale:
CO(6) Application-Frazier, p90 Rationale:Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis
A nurse is caring for a client who is receiving warfarin therapy to prevent a deep vein thrombosis. Which of the following medications should the nurse have available in the event of an overdose?
1) Epinephrine
2) Atropine
3) Protamine
4) Vitamin K
4) Vitamin K
Answer Rationale:
The nurse should have available vitamin K available to reverse the effects of warfarin in the event of an overdose.
The nurse received an order to administer vancomycin 500mg intravenously every 8 hours. What type of infusion is this?
1) continuous infusion
2) bolus injection
3) piggyback infusion
4) maintenance infusion
3) piggyback infusion
Answer Rationale:
Application, CO 3, Frazier p86 Rationale- Vancomycin intravenously is medication dissolved in a smaller amount. This type of administration is often used for dosages to be administered at regular intermittent intervals.
The nurse experienced a needlestick after obtaining a patient's labs. What is the first thing the nurse should do following the needlestick?
1) notify the charge nurse
2) write an incident report in the patients chart
3) clean the site
4) notify the supervisor.
3) clean the site
Answer Rationale:
Application, CO 3, Frazier p42 Rationale- the nurse should first clean the site and then notify the supervisor. The incident would not go in the patient's chart.
The chain of infection consists of what stages?
1) Infectious agent
2) portal of entry
3) portal of exit
4) portal of reentry
5) mode of transmission
1) Infectious agent
2) portal of entry
3) portal of exit
5) mode of transmission
Answer Rationale:
Knowledge, CO 2, Frazier p36 Rationale- the chain of infection starts with an infectious agent, reservoir host, portal of exit, mode of transmission, portal of entry, and final is susceptible host.
A nurse is assessing an intravenous infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration?
1) Blood in the intravenous tubing
2) Absence of blanching at the insertion site
3) Edema in the palm of the hand
4) Warmth around the insertion site
3) Edema in the palm of the hand
Answer Rationale:
CO(6) Application- Frazier p 87 Rationale:Blood in the IV tubing can indicate disconnection of the catheter from the tubing. Blanching at the insertion site, not absence of blanching, indicates an infiltration. Edema, pallor, and coolness around the insertion site indicate a collection of fluid leaking into subcutaneous tissue, also known as an infiltration. An infiltration causes coolness around the insertion site. Warmth indicates phlebitis.
What materials are necessary when preparing to start an IV?
1) Gloves
2) Gown
3) IV start kit
4) IV catheter
5) Saline Flush
1) Gloves
3) IV start kit
4) IV catheter
5) Saline Flush
After drug administration, the nurse should monitor for which responses to drug therapy? Select all that apply.
1) Expected outcomes
2) Premedication teaching
3) Allergic responses
4) Adverse reactions
5) Side effects
1) Expected outcomes
3) Allergic responses
4) Adverse reactions
5) Side effects
Answer Rationale:
Application, CO 4, ATI p15 Rationale: Part of evaluation. monitor for allergic reactions, adverse reactions, side effects, and expected outcomes. Teaching is done prior to medication administration.
A nurse has administered the wrong medication to a patient. Which is the highest-priority nursing action at this time?
1) Document the occurrence in the patient record.
2) Notify the immediate supervisor of the error.
3) Complete an incident report and submit it to the nurse manager.
4) Evaluate the patient’s condition and notify the physician.
4) Evaluate the patient’s condition and notify the physician.
Answer Rationale:
Application, CO 4, ATI p15 Rationale- evaluating the patient takes priority followed by notifying the physician. The notifying the supervisor and completing an incident report occur after.
The Occupational Safety and Health Administration Bloodborne Pathogens Standards address the following: Select all the apply.
1) Exposed control plans
2) Labeling requirements
3) Record keeping
4) Communication of hazards to employees
Answer Rationale:
CO (2) Knowledge-Frazier p. 41 Rationale: OSHA, an agency of the federal government, was established in 1970 to guarantee safe working environments for all employees and lower the incidence of occupational hazards.
1) Exposed control plans
2) Labeling requirements
3) Record keeping
4) Communication of hazards to employees
Answer Rationale:
CO (2) Knowledge-Frazier p. 41 Rationale: OSHA, an agency of the federal government, was established in 1970 to guarantee safe working environments for all employees and lower the incidence of occupational hazards.
Complications of intravenous therapy can be caused by different origins. What are the different types of complications? Select all that apply
1) Local
2) System
3) Musculoskeletal
4) Neurological
1) Local
2) System
A group of nurses are reviewing surgical asepsis. Which statements by one of the nurses requires further teaching on the topic? Select all that apply.
1) “Full-strength chlorhexidine will sterilize the skin.”
2) “The edges of a sterile field are considered unsterile.”
3) “If a sterile object touches an unsterile object, the sterile object is considered contaminated.”
4) “Sterile objects that are out of view or below waist level are considered unsterile.”
5) “Airborne microorganisms can contaminate sterile objects and make them unsterile.”
6) “It is ok to reach over a sterile field if gloves are worn.”
1) “Full-strength chlorhexidine will sterilize the skin.”
Answer Rationale:
Application. The skin cannot be sterilized, according to the principles of surgical asepsis. The edges of a sterile field are considered unsterile. If a sterile object touches an unsterile object, the sterile object is considered contaminated. Sterile objects that are out of view or below waist level are considered unsterile. Sterile objects can become contaminated by airborne microorganisms. CO 3,4