Ch 26
Which body organ is primarily responsible for medication excretion?
The kidneys are the primary site of excretion. If the patient has decreased renal function, the nurse should closely monitor for medication toxicity.
A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. Which type of charting is the nurse using?
1. Narrative charting
2. Charting by inclusion
3. Charting by exception
4. Source-oriented charting
Charting by exception is a system of charting where only exceptions to the normal findings or to the unit standards are charted. These are directed by organizational, professional, and legal guidelines.
The nursing student is preparing to administer an intramuscular (IM) injection to the patient. The student states to the instructor, “I’m going to administer this medication in my patient’s buttocks at the dorsogluteal site.” What is the most appropriate response by the instructor?
The dorsogluteal site consists of the gluteal muscles of the buttocks. Avoid using the dorsogluteal site for IM injections because its close proximity to the sciatic nerve and superior gluteal artery increases the risk of injection into a major blood vessel and damage to the sciatic nerve. Furthermore, the site is difficult to identify accurately in older adults or people with flabby skin. The instructor should advise the student that this is not the appropriate site and elicit another site from the student.
Which prescription would the nurse question since it is inconsistent with the standards established by The Joint Commission?
1. Administer Lasix 20 mg PO daily at 1000.
2. Administer Lasix 10.0 mg PO daily at 1000.
3. Administer digoxin 10 mg PO daily at 1000.
4. Administer digoxin 0.3 mg IV daily at 1000.
The nurse would question this order because it is inconsistent with the standards by The Joint Commission. The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors. The trailing zero should not be used in medication prescriptions; thus, 10.0 mg is incorrect. It should be correctly written as 10 mg.
What is the most essential action by the nurse prior to delegating the administration of an intravenous (IV) medication to a licensed practical nurse (LPN)?
1. Review the state’s nurse practice act for LPN scope of practice.
2. Examine the unit policy and procedure for IV medication administration.
3. Determine whether the LPN has previously performed this procedure.
4. Demonstrate the procedure; then allow the LPN to administer the IV medication.
The State Board of Nursing regulates the types and routes of medications that can be administered by the various levels of nurses. For example, LPNs in some states cannot administer IV medications, whereas other states require additional education and experience before LPNs can perform this action.
The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?
1. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN
2. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. TO Dr. D. Kelly/Kay Andrews, RN
3. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Dr. D. Kelly/Kay Andrews, RN
4. 09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain. VO Kay Andrews, RN
Correct documentation of a telephone order is as follows: “09/02/19 0845 morphine 4 mg intravenously q 1 hour prn pain TO Dr. D. Kelly/Kay Andrews, RN” (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber’s name and title, nurses name and title.)
Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site?
1. Apply a warm compress.
2. Massage the site in a circular motion.
3. Apply a soothing lotion.
4. Have the client assume a sitting position.
To relax the vastus lateralis for injection, the nurse should have the client assume a sitting position or lie flat.
Why might a healthcare provider choose narrative charting instead of using forms or checklists?
1. Narrative charting tracks the client’s changing health status as it occurs.
2. Free form documentation is inconsistent among healthcare providers.
3. Less charting time by healthcare provider is needed for narrative charting.
4. Less interdisciplinary discussion occurs with the narrative style of charting
A narrative chart entry tells the story of the client’s experience as it occurs in a chronological format with the goal to track a client’s changing medical and health status. It also documents progress toward goals for the client.
Which documentation entry related to prn (as needed) medication administration is complete?
1. 6/5/20 0900 morphine 4 mg IV given in right antecubital fossa for pain rated 8 on a 1–10 scale, J. Williams RN
2. 0600 famotidine 20 mg IV given in right hand, S. Abraham RN
3. 9/2/20 0900 levothyroxine 50 mcg PO given
4. 1/16/20 furosemide 40 mg PO given, J. Smith RN
The option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a prn order, the nurse also included the reason the medication was administered.
The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates the nurse is following the surgeon’s order?
1. Performs oral care
2. Assists the patient out of bed
3. Helps the patient with bathing
4. Changes the patient’s operative dressings
2. Assists the patient out of bed