Question 1

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse? A)Chooses to administer 50 mcg of the prescribed 50-100 mcg of IV fentanyl for the first dose B)Dilutes hydromorphone with 5 mL of normal saline and injects IV push over 2 minutes C)Injects 1 mg of morphine sulfate undiluted via IV push over 5 minutes D)Selects a 25-gauge ½-inch (1.3-cm) needle to inject ketorolac intramuscularly

Accepted Answer

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) analgesic administered (orally, IV, or intramuscularly [IM]) for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects (eg, kidney injury, gastrointestinal ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is recommended to inject medication into the proper muscular space in average-weight individuals. (Option A) The amount of analgesic to administer of a variable dose medication should be based on the client's pain level, level of consciousness, and history of narcotic use. Selecting a smaller first dose is appropriate if the nurse is unsure of how the client will respond to the medication. If needed, the larger amount can be given the next time a dose is requested or an additional one-time dose can be requested from the health care provider if breakthrough pain occurs (before the next scheduled medication dose is available). (Option B) Hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or normal saline, should be administered slowly over 2-3 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, nausea, itching). (Option C) Undiluted morphine IV push should be administered slowly over 4-5 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing). Educational objective: Ketorolac, a nonsteroidal anti-inflammatory drug, is used for short-term (≤5 days) pain relief due to risk of bleeding, gastrointestinal ulcers, and kidney injury. Intramuscular (IM) injections (using Z-track method) should be given deep into a large muscle due to burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is used to reach the proper muscle space.

Question 2

The nurse is caring for a 2-year-old who is refusing oral antibiotics. What is the nurse's next action? A)Ask the health care provider to switch to IV antibiotics B)Hide the antibiotic in the child's favorite food or beverage C)Offer the child a choice of orange or apple juice with the antibiotic D)Tell the child that the medication tastes just like candy

Accepted Answer

Toddlers (age 1-3) begin to demand autonomy and have a strong desire for independence. Negativistic behavior is common, and questions requiring a yes or no response should not be used. Offering limited choices will give the toddler a sense of control. Allowing the toddler to choose between orange or apple juice should improve cooperation. (Option A) The nurse should not call the health care provider without trying other age-appropriate techniques first. (Option B) Medications should never be hidden in foods or beverages. Pancreatic enzymes, given for cystic fibrosis, can be mixed in applesauce. (Option D) Medication should not be referred to as candy as this increases the risk for a toxic ingestion. The child might decide to eat the medication thinking that it is candy. Educational objective: The need for control is common during the toddler stage of psychosocial development, and administering oral medications can be challenging. The nurse should offer the toddler limited choices and avoid questions that require a yes or no response.

Question 3

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route.  The nurse intervenes when the student performs which action?
A)Advances tip of needle through epidermis until the bevel is no longer visible under the skin
B)Chooses a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle; dons clean gloves
C)Injects medication slowly while raising a small wheal (bleb) on the skin
D)Inserts needle at a 10-degree angle almost parallel to skin with the bevel up

Accepted Answer

11ecbb05_cb33_2512_b433_819b8ea80f5c_MD0009_00 Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: Choose a1 mLtuberculin syringe with a27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option B). Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option D). Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option A). Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option C). Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction. Educational objective: For TB skin testing: Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm at a 10-degree angle with bevel up Make a wheal (bleb) Avoid rubbing site after injection

Question 4

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? Select all that apply. A)Apply patch to the upper arm or chest B)Fold used patches in half with sticky sides together before discarding C)Remove patch if dizziness occurs when getting up D)Rotate sites each time a new patch is applied E)Shave hair before applying patch

Accepted Answer

11ecbb05_cb3f_cf4b_b433_954956268be5_MD0009_00 Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the clonidine (transdermal) patch: Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days (Option A). Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars (Option E). Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. Remove the patch from the package. Do not touch the sticky side. Rotate sites of patch application with each new patch (Option D). Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP). When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested (Option B). Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur (Option C). Educational objective: The nurse should teach a client receiving a clonidine patch to: Apply patch to a dry hairless area on the upper arm or chest Wash hands before and after application Rotate sites with each new patch application Discard patch away from children or pets with sticky sides folded together Never wear more than 1 patch at a time Never stop using the patch abruptly

Question 5

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen.  The nurse intervenes when the student performs which action?
A)Instills ear drops at room temperature
B)Instills ear drops with dropper by occluding the ear canal
C)Places a cotton ball loosely in outermost auditory canal after the instillation
D)Pulls pinna up and back and instills drops

Accepted Answer

11ecbb05_cb3a_9f27_b433_81dd19ec8d5f_MD0009_00 Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum. The general procedure for instilling ear drops includes the following steps: Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes (Option A) Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old (Option D) Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper (Option B) Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard (Option C) Educational objective: To administer otic medications in an adult client, follow these steps: (1) Perform hand hygiene, (2) position the client side-lying with the affected ear up, (3) pull pinna up and back, (4) administer prescribed number of ear drops, (5) instruct the client to remain side-lying for 2-3 minutes, and (6) place cotton ball loosely in the outer ear canal for 15 minutes (if needed).

Question 6

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. A)"I can mix the medication in a bowl of my child's favorite cereal." B)"I should give another dose if my child vomits after taking the medication." C)"I should measure liquid medications using an oral syringe." D)"I will encourage my child to help me as I prepare the medication." E)"I will place my child in time-out if the medication is refused."

Accepted Answer

For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option C). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option D). (Option A) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option B) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option E) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective: For pediatric clients, liquid medication should be measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

Question 7

The nurse teaches a client with newly diagnosed Sjögren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching? A)"After applying the ointment, I'll tightly close my eyes and rub the lid for 2-3 minutes." B)"I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge." C)"I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment." D)"I'll use my ointment at bedtime and my eye drops during the day."

Accepted Answer

11ecbb05_cb36_3254_b433_818532da6634_MD0009_00 Ophthalmic lubricants (drops, ointment, gel) replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjögren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment. (Option B) This statement indicates the client's understanding that when self-administering the medication, the client should squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge, and without letting the tube touch the eye to prevent contamination. (Option C) This statement indicates the client's understanding that when self-administering the medication, the client tilts the head back, pulls the lower lid down, and looks toward the ceiling to help decrease blink reflex. (Option D) Some clients use the ophthalmic ointment at bedtime and the eye drops during the day due to blurred vision that ointments and gels can cause. Educational objective: Teach client the following steps for self-administration of ophthalmic ointments: Perform hand hygiene Tilt the head back, pull the lower lid down, and look upward Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge Close the eyes gently for 2-3 minutes after applying the ointment

Question 8

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. A)Advance past the external sphincter only B)Guide suppository along the rectal wall C)Hold buttocks together firmly after insertion D)Position client supine with knees and feet raised E)Use gloved fifth finger for insertion

Accepted Answer

11ecbb05_cb3e_96ca_b433_5169ecff7b03_MD0009_00 Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following: Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option D). Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option E). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option B). suppository Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option C). If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository. (Option A) The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect. Educational objective: In children younger than age 3 years, suppositories are inserted with the fifth finger of the nurse's gloved hand. Age-appropriate explanations and/or distractions are implemented to reduce distress.

Question 9

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? A)Check the health care provider's prescription in the medical record B)Explain that the health care provider has prescribed the medication C)Look up the medication in the pharmacology reference D)Teach the client about the purpose of the medication

Accepted Answer

Safe medication administration is conducted according to 6 rights: Right client using 2 identifiersRight medicationRight doseRight routeRight timeRight documentation Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option A). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option B) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option C) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option D) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

Question 10

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply. A)Apply a heating pad over the patch to aid drug absorption B)Cut the patch in half before application if less medication is needed C)Fold the used patch in half so that the edges adhere and immediately discard D)Place the patch 1 in (2.5 cm) from the source of pain for maximal effectiveness E)Remove the old patch when applying a new patch every 72 hours

Accepted Answer

Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one (Option E). Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers (Option C). (Option A) Heat (eg, heating pad) should not be placed over a patch as this accelerates absorption. (Option B) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option D) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain. Educational objective: Fentanyl patches are changed every 72 hours, and used patches must be folded and discarded securely before a new one is applied. Patches should be applied to flat, intact skin to prevent accidental removal. Patches should not be cut, and heat should not be placed over them.

Question 11

The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor? A)Discourages the client from rubbing the injection site after the injection B)Ejects the air bubble from the prefilled syringe before administration C)Inserts the needle and injects the medication at a 90-degree angle D)Selects an injection site on the left lateral side of the abdomen

Accepted Answer

11ecbb05_cb3c_9af8_b433_71736f7c7c05_MD0009_00 Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error (Option B). (Option A) After subcutaneous anticoagulant injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. (Option C) A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped. (Option D) Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall (ie, "love handles"), at least 2 in (5 cm) away from the umbilicus. Educational objective: Low-molecular-weight heparin is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose during injection. The nurse should not expel the air bubble prior to administration as this could result in some medication being left in the syringe and an incomplete dose delivery.

Question 12

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? A)Instructs client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30-60 seconds B)Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac C)Removes dried secretions with moistened sterile gauze pads by wiping from the outer to inner canthus D)Rests hand on client's forehead and holds dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac

Accepted Answer

If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct (Option C) Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination (Option D) Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac (Option B) Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption (Option A) Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination Wait 5 minutes before instilling a different medication into the same eye Educational objective: To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate).

Question 13

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD).  Which statement indicates that the client has a correct understanding of this medication?
A)"A capsule holds the powdered medication that I have to put in a special inhaler."
B)"I do not need to rinse my mouth with water after taking tiotropium."
C)"I have been taking tiotropium every time I have difficulty breathing."
D)"Tiotropium helps control my COPD by reducing inflammation in my airway."

Accepted Answer

11ecbb05_cb40_b9ac_b433_e993b891d42d_MD0009_00 Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option B) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. (Option C) Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option D) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions. Educational objective: Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for COPD and asthma. Tiotropium is typically administered as a powder via a special inhaler.

Question 14

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic.  Which method of injection would be appropriate for this client?
A) 
B) 
C) 
D)

Accepted Answer

11ecbb05_cb41_a411_b433_dbde04b78ef0_MD0009_00 When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation. The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option B). Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus. (Option A) A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue. (Option C) A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped). (Option D) Needles longer than ⁵⁄₈ in (1.6 cm) are used to administer intramuscular injections. Educational objective: Anticoagulant injections should be administered in the abdominal subcutaneous tissue at a 45- to 90-degree angle. A 45-degree angle is used for clients with minimal adipose tissue to avoid accidental intramuscular injection, which would cause rapid absorption and result in hematoma and painful muscle irritation.

Question 15

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply. A)Check laboratory values before administering anticoagulants B)Compare medication, dosage, and route to prescription orders prior to administration C)Discard any unlabeled medications D)Open unit dose packages and place medications in a dispensing cup to take to the bedside E)Wear gloves to handle unopened individual unit dose medication packages

Accepted Answer

The nurse must follow the 6 rights of medication administration: The right client The right medication The right dose The right time The right route The right documentation Additionally, one of the National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. (Option D) Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration. (Option E) Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or body fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers). Educational objective: The nurse should follow the 6 rights of medication administration when preparing and administering drugs to a client. Additionally, the NPSGs of improving the safety of using medications should be followed, including labeling all medications, discarding medications found unlabeled, and taking extra care for clients taking anticoagulant drugs.

Question 16

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old.  Which is an appropriate action by the nurse?
A)Have the child sit upright with the chin tilted down
B)Pull the pinna upward and back
C)Remove the medication from the refrigerator just before use
D)Touch the dropper to the entrance of the ear canal

Accepted Answer

11ecbb05_cb39_dbd5_b433_dd4139913898_MD0009_00 When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal (Option B). For an infant, the pinna is pulled downward and straight back. (Option A) The child should be placed in the prone or supine position with the head turned to the appropriate side. (Option C) Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting in dizziness and vomiting. (Option D) The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication. Educational objective: When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

Question 17

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used. A)Apply gentle pressure at the injection site but do not massage B)Inject medication slowly with dominant hand while maintaining traction C)Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle D)Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site E)Release the hold on the skin, allowing the layers to slide back to their original position F)Wait 10 seconds after injecting the medication and withdraw the needle

Accepted Answer

11ecbb05_cb3d_ac69_b433_0968b5336314_MD0009_00 The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps: Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option D). Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle (Option C). Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication (Option B). Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking (Option F). Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track (Option E). Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation (Option A). There is no clear evidence to support the need for aspiration prior to IM injection. Aspiration may be indicated if the dorsogluteal site (last resort) is used for IM injection due to its proximity to the gluteal artery. The preferred areas for IM injection are the ventrogluteal site in adults and the vastus lateralis site in children. Educational objective: The Z-track technique for administering IM injections prevents tracking (leakage) of the medication into the subcutaneous tissue.

Question 18

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply. A)Add the medication to the bottle of formula before feeding B)Direct liquid medication toward the inside of the infant's cheek C)Hold the infant in a semi-reclining position during administration D)Measure and administer the medication using an oral syringe E)Open the infant's mouth by gently pinching the nose shut

Accepted Answer

11ecbb05_cb3a_5106_b433_c91850961283_MD0009_00 Giving oral medications to infants requires specialized techniques for safe administration. A plastic, disposable oral syringe can be used for accurate dosing and ease of delivery (Option D). Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position (Option C). This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid medications administered by oral syringe should be directed toward the back and inside of the infant's cheek (Option B). The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration. (Option A) Medications are never mixed in a bottle of infant formula as this can affect the taste and the infant may then refuse the formula in the future. In addition, if the infant does not complete the full feed, underdosing will occur. (Option E) Pinching the nose shut during medication administration may cause aspiration. The infant's mouth should be opened by applying gentle pressure to the chin or cheeks. Educational objective: Disposable oral syringes are the preferred tool to administer oral medications to infants. Infants should be held in a semi-reclining position, and medications should be given slowly in small amounts directed toward the back and inside of the cheek.

Question 19

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching? A)A sitting position is assumed as the head is bowed slightly forward B)The client points the spray tip toward the nasal septum during instillation C)The nasal spray tip is inserted into the nostril as the other nostril is occluded D)While administering the medication, the client inhales deeply through the nose

Accepted Answer

The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to: Assume a high Fowler's position with head slightly tilted forward (Option A) Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (Option C) Point the nasal spray tip toward the side and away from the center of the nose (Option B) Spray the medication into the nose while inhaling deeply (Option D) Remove the nozzle from the nose and breathe through the mouth Repeat the above steps for the other nostril Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation Educational objective: The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose.

Question 20

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client.  The nurse knows that the parent understands the teaching when the parent does which of the following?
A)Allows the client to sip the medication from a cup
B)Expels the medication from a dropper onto the back of the tongue
C)Mixes the medication in the infant's bottle of formula
D)Using a syringe, administers the medication in small amounts into the back of the cheek

Accepted Answer

11ecbb05_cb35_e433_b433_9be8de2dc51f_MD0009_00 Using a syringe to measure the medication is the most accurate technique to ensure that the proper amount of medication is being administered. The correct procedure for administering oral medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk for choking and ensures that all the medication is consumed. (Option A) Although cup feeding may be a method used to feed infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infant's spitting or drooling. (Option B) Infants have a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration of the medication. (Option C) It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount. Educational objective: The extrusion reflex and a decreased gag reflex in infants less than 4 months old increase the risk for choking and aspiration. Instilling the medication using a syringe at the back of the cheek decreases the risk for choking and ensures that the correct amount of medication is consumed.

Exam 4: Fundamentals

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse?

The nurse is caring for a 2-year-old who is refusing oral antibiotics. What is the nurse's next action?

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action?

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include? Select all that apply.

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action?

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.

The nurse teaches a client with newly diagnosed Sjögren's syndrome how to self-administer ophthalmic lubricating ointment medication. Which statement that the client makes indicates the need for further teaching?

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next?

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which instructions related to this medication should the nurse provide? Select all that apply.

The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor?

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed?

The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD) . Which statement indicates that the client has a correct understanding of this medication?

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client?

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse?

A nurse administers an intramuscular (IM) injection using the Z-track technique. Place the steps in chronological order. All options must be used.

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? Select all that apply.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the nurse to intervene and provide further teaching?

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client. The nurse knows that the parent understands the teaching when the parent does which of the following?