Med Administration
This is the generic name for the medication commonly sold under the brand name Tylenol
acetaminophen
According to Erikson, this is the psychosocial conflict experienced during adolescence as the person develops a sense of self and direction in life.
Identity versus role confusion
This is the expected resting respiratory rate range for a healthy adult.
12-12 breaths per minute
This type of IV solution has the same osmolality as blood, resulting in no net movement of water into or out of cells.
isotonic solution
This ethical principle refers to a patient’s freedom to make their own healthcare decisions without external control.
autonomy
This pharmacokinetic process occurs when a medication is changed into a less active or inactive form so that it can be more easily removed from the body.
metabolism
The nurse teaches the parents of a healthy infant to use these three “ABCs” to create a safe sleep environment.
alone, on the back, and in a crib
These five elements help the nurse determine whether a task can be delegated safely. Name 3!
right task
right circumstance
right person
right direction
right communication
right supervision
right evaluation
Nurses use this standardized communication format to organize the situation, relevant background, assessment findings, and recommendation when reporting a patient concern.
SBAR
A patient reports a sudden, strong need to urinate followed by involuntary loss of urine before reaching the bathroom. This type of urinary incontinence is occurring.
urge incontinence
A nurse prepares to administer an intradermal injection for a skin test. This is the correct angle of insertion.
5 to 15 degrees
A patient has experienced knee pain and stiffness from osteoarthritis for several years. The pain affects daily activities and requires ongoing management. This is the best classification of the patient’s pain.
chronic persistent noncancer pain
A patient’s apical pulse is 96 beats/min, while the radial pulse is 82 beats/min. This is the patient’s pulse deficit.
14 beats per minute
A patient has gained 2 kg in 24 hours, has bilateral crackles, distended neck veins, edema, and an elevated blood pressure. These findings indicate this fluid imbalance.
fluid volume excess, or hypervolemia
A postoperative patient is unable to completely empty their bladder. The nurse reviews the medication list and identifies this class of medication as a possible contributor because it inhibits bladder contractility.
anticholinergic medications
Two hospitalized patients have the same last name. Before administering a medication, the nurse should use this as approved patient identifiers. Name 3!
patient's name
MRN number
Birth date
A postoperative patient reports severe pain of 8/10 and has an order for IV morphine. Before administering the medication, the nurse must take this priority action. Name 2!
assess pain
vital signs
respiratory status
assessment
A patient’s blood pressure is 126/78 mm Hg while supine and 102/64 mm Hg after standing. This condition is indicated by the patient’s vital-sign changes.
orthostatic hypotension
A patient declines breakfast and lunch. Instead of documenting, “The patient was difficult and would not eat,” the nurse should use this type of language and include the patient’s response and nursing interventions.
objective or factual documentation
A nurse observes a break in sterile technique during a procedure. Although told by another healthcare professional to ignore it, the nurse reports the concern because preventing harm to the patient takes priority. This ethical principle is most directly demonstrated.
nonmaleficence
A 72-year-old patient with pneumonia and dehydration has nausea and has vomited twice. The provider prescribes medication to control the nausea. Of the PO, IM, and IV routes, this route is safest and most effective because the patient may not retain an oral medication and needs a reliable response.
IV route
An older adult receiving IV morphine is difficult to arouse and has a respiratory rate of 7 breaths/min and an oxygen saturation of 86%. This opioid complication requires the nurse’s immediate attention.
respiratory depression
The nurse is caring for four patients:
This is the patient the nurse should assess first.
patient with sudden chest pain and shortness of breath
A patient receiving packed red blood cells suddenly develops shortness of breath, chest discomfort, chills, and confusion. This is the nurse’s first action.
immediately stop the transfusion
run regular fluids
assess
stay with the patient
An adult patient has produced only 50 mL of urine over the last 2 hours and reports lower abdominal pressure. Before assuming the kidneys are failing or immediately catheterizing the patient, the nurse should perform this noninvasive assessment.
perform a bladder scan to assess for urinary retention