Med Admin & Safety
What are the 6 rights of medication administration?
Right patient, Right drug, Right dose, Right route, Right time, Right documentation
How should the nurse collect a urine sample from a foley catheter?
Answer: From the port using a sterile syringe, never from the drainage bag
Rationale: The bag is not sterile. Use the sample port and follow proper cleaning technique.
What nursing action helps prevent aspiration in a patient with dysphagia?
Sit patient upright (90 degrees) during and after meals; thicken liquids if ordered.
Define subjective versus objective data and provide an example of each.
Subjective data = this is something only the patient can report. It's based on the patient’s feelings, experiences, or perceptions. e.g “I feel nauseous.”
Objective data = what the nurse observes or measures. It’s factual, measurable, and observable by others. e.g., blood pressure reading of 150/90 mmHg.
A nurse is verifying a verbal medication order over the phone. What must the nurse do?
A. Ask another nurse to listen in
B. Repeat the order back to the provider
C. Administer the medication immediately
D. Wait until morning to verify the order
B. Repeat the order back to the provider
Rationale: A verbal order is when a provider speaks a medication order out loud (often over the phone or in emergencies) instead of writing it. When receiving a verbal or telephone medication order, the nurse must always perform a read-back. This means:
Repeat the order word-for-word back to the provider.
Confirm the drug name, dosage, route, frequency, and any clarifying details.
Then document that the order was read back and verified.
When should a nurse wear goggles or a face shield?
A. When suctioning a tracheostomy
B. When taking vital signs
C. When walking into a patient’s room
D. When changing bed linens
A. When suctioning a tracheostomy
Rationale: Procedures that may result in splashes of bodily fluids (like suctioning) require eye protection (goggles or face shield).
A nurse is caring for a patient on a clear liquid diet. Which of the following foods is appropriate?
A. Cream of chicken soup
B. Apple juice
C. Ice cream
D. Milk
B. Apple juice
Rationale: Clear liquids = transparent at room temp. Milk and ice cream are full liquids, cream soup is not allowed.
A client has an irregular radial pulse. What should the nurse do next?
A. Record the finding as normal
B. Count the pulse for 15 seconds
C. Compare it to the carotid pulse
D. Auscultate the apical pulse for 1 full minute
D. Auscultate the apical pulse for 1 full minute
Rationale: An irregular pulse must be confirmed by listening to the apical rate, this gives the most accurate count and rhythm.
Which of the following is an example of a medication reconciliation error?
A. Not scanning the patient’s wristband
B. Administering a medication without checking labs
C. Omitting a patient’s home medication during admission
D. Giving a medication 10 minutes late
C. Omitting a patient’s home medication during admission
Rationale: This is a medication reconciliation error, which happens during transitions of care. All home meds must be reviewed and reconciled.
A nurse is removing PPE after caring for a TB patient. Which item should be removed last?
A. Gloves
B. Gown
C. Goggles
D. N95 Respirator
Answer: D
Rationale: When removing PPE after caring for a patient with airborne precautions (like TB), the N95 respirator should be removed last to ensure the nurse is still protected from any airborne particles that may be present in the environment until fully out of the isolation room.
What is the difference between enteral and parenteral nutrition?
Answer:
Enteral: Nutrition via the GI tract (e.g., feeding tube).
Parenteral: Nutrition via IV (bypasses GI tract).
Rationale: Depends on GI tract function.
The nurse is assessing a client's respiratory rate. Which action will provide the most accurate reading?
A. Ask the patient to breathe normally while counting
B. Tell the patient you’re counting their breathing
C. Count respirations while pretending to take the pulse
D. Count for 15 seconds and multiply by 4
C. Count respirations while pretending to take the pulse
Rationale: This prevents the patient from altering their breathing and gives the most accurate rate.
A patient with a gastrostomy tube is prescribed enteric-coated tablets. What should the nurse do?
A. Crush and dissolve the medication
B. Hold the dose and notify the provider
C. Administer through the tube with extra water
D. Mix it with food and give orally
B. Hold the dose and notify the provider
Rationale: Enteric-coated tablets are designed to dissolve in the intestines, not the stomach. Crushing or altering them can damage the protective coating, causing irritation to the stomach lining, inactivation of the drug, reduced effectiveness, or increased side effects. So, you hold the dose to avoid harming the patient and to stay within your legal scope of practice. You then notify the provider for further instructions.
A nurse is caring for a client with Clostridium difficile (C. diff). Which type of precautions should be implemented?
A. Droplet precautions
B. Airborne precautions
C. Standard precautions
D. Contact precautions
D. Contact precautions
Rationale: C. diff requires contact precautions because it spreads via contaminated surfaces. Soap and water must be used for hand hygiene (not alcohol-based sanitizers).
A nurse notes that a postoperative client has not voided for 8 hours. What should the nurse do first?
A. Administer a diuretic
B. Notify the provider
C. Perform a bladder scan
D. Insert a foley catheter
C. Perform a bladder scan
Rationale: First assess for urinary retention before calling the provider or inserting a catheter. It’s a non-invasive, quick check.
Explain orthostatic hypotension
Orthostatic hypotension is a drop in blood pressure that happens when a person moves from lying down to sitting or standing.
What does a STAT medication order mean, and how soon should a STAT medication be administered once ordered?
Answer: A STAT medication is used during emergencies, and the order be given "immediately," typically within 30 minutes.
Rationale: STAT orders are used in emergencies or urgent situations to stabilize the patient. A STAT medication order should generally be administered within 30 minutes of it being ordered.
Describe the process for donning and doffing PPE in the correct order.
Donning: Gown → Mask → Goggles → Gloves
Doffing: Gloves → Goggles → Gown → Mask
What is the term for difficulty urinating?
Answer: Dysuria
Rationale: Often related to infection or obstruction.
The nurse is checking capillary refill and notes it takes 5 seconds for color to return. What does this indicate?
A. Normal peripheral perfusion
B. Dehydration
C. Delayed capillary refill
D. Increased cardiac output
C. Delayed capillary refill
Rationale: Normal refill is <2 seconds. 5 seconds indicates poor perfusion, which could be due to shock, hypothermia, or dehydration.