Chapter 25. Medicating Patients My Nursing Test Banks

Chapter 25. Medicating Patients

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription?

1)

Chemical

2)

Brand

3)

Trade

4)

Generic

ANS: 4

Furosemide, the generic name, was used by the physician in the drug order. The brand or trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid.

PTS:1DIFifficultREF:p. 746

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

____ 2. A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication?

1)

Inform the prescriber that she is not comfortable administering the drug.

2)

Ask a nursing colleague for relevant information about the drug.

3)

Consult the drug formulary accessible to staff at the patient care unit.

4)

Trust the prescriber writes the dose and administer the drug as intended.

ANS: 3

The nurse is responsible for every medication she administers. Therefore, the nurse must be familiar with the indications, routes of administration, dosages, contraindications, adverse reactions, drug interactions, and any special administration guidelines associated with each drug before administration. There are numerous ways to become more informed about medication, such as a drug formulary, Physicians Desk Reference, or registered pharmacist before administration. The nurse should not rely on information from a colleague because as a secondary source of information, there is a risk for inaccuracy, which can be dangerous in a patient care situation.

PTS:1DIF:ModerateREF:pp. 746-747

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 3. A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed?

1)

Seek clarification from the surgeon about the medication order.

2)

Clamp the NG tube while administering the dose by mouth.

3)

Instill the medication through the NG tube.

4)

Withhold the oral potassium chloride elixir.

ANS: 1

The nurse should seek clarification from the surgeon about the medication ordered via the nasogastric route. If the patient has a nasogastric tube in place to release gastric drainage, any medication given by mouth would be lost into the drainage collection unit and, therefore, be unavailable to the patient for therapeutic use. The nurse does not have authority to electively withhold or alter the route of prescribed treatment without seeking clarification and resolving any discrepancy in the route by which the medication would be administered.

PTS: 1 DIF: Moderate REF: pp. 750, 767

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 4. A patient calls the nurse because he is having incision pain and wants a dose of analgesic medication. When the nurse checks the patients medication administration record, she notes that he is prescribed the narcotic, hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drug for administration?

1)

Cabinet in the patients room

2)

Double-locked medication drawer

3)

Stock supply cabinet

4)

Portable medication cart

ANS: 2

Hydromorphone (Dilaudid) is a controlled substance and must be kept in a double-locked medication drawer for control of inventory. Frequently used Schedule II medications, such as ibuprofen, are stored in the stock supply. Other prescribed medications may be stored in a locked cabinet in the patients room or in the medication cart.

PTS:1DIF:ModerateREF:pp. 747-748

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 5. Which term refers to the movement of a drug from the site of administration to the bloodstream?

1)

Absorption

2)

Distribution

3)

Metabolism

4)

Excretion

ANS: 1

Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excreted from the body. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands.

PTS:1DIF:ModerateREF:p. 749

KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall

____ 6. A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief?

1)

Liquid acetaminophen with codeine

2)

Intravenous morphine sulfate

3)

Intramuscular meperidine

4)

Oral oxycodone tablets

ANS: 2

Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act more quickly than drugs administered by the oral or intramuscular routes.

PTS: 1 DIF: Moderate REF: pp. 750-753

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 7. The time it takes for drug concentration to reach a therapeutic level in the blood is known as:

1)

peak action.

2)

duration of action.

3)

onset of action.

4)

half-life.

ANS: 3

The onset of action is the time needed for drug concentration to reach a high enough level in the blood for its effects to appear. Peak action occurs when the concentration of a medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amount of time required for half of the drug to be eliminated.

PTS:1DIF:ModerateREF:p. 755

KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

____ 8. A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug?

1)

0930

2)

1000

3)

1100

4)

1500

ANS: 4

The nurse should no longer see the effects of furosemide around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak diuresis should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario above.

PTS:1DIF:EasyREF:p. 755

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 9. Which factor in a patients medical history is most likely to prolong the half-life of certain drugs?

1)

Heart disease

2)

Liver disease

3)

Rheumatoid arthritis

4)

Tobacco use

ANS: 2

Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g., because of liver disease), the drug will be eliminated more slowly, prolonging the drugs half-life. Tobacco use can increase the elimination of some drugs, decreasing their effectiveness.

PTS:1DIF:ModerateREF:p. 754

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 10. The nurse receives a laboratory report that states her patients digoxin level is 1.2 ng/mL; therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take?

1)

Notify the prescriber to reduce the dose.

2)

Withhold the next dose of digoxin.

3)

Administer the next dose as prescribed.

4)

Notify the prescribing healthcare provider to increase the dose.

ANS: 3

Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patients level is within the therapeutic range, so the nurse should administer the next dose as prescribed. The dose should not be increased or decreased because the prescribed dose is producing a level within the therapeutic range. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient.

PTS:1DIFifficultREF:pp. 755-756

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 11. The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough?

1)

With the morning routine laboratory studies

2)

Approximately 30 minutes before the next dose

3)

Two hours after the next dose infuses

4)

While the drug infuses

ANS: 2

Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. Therefore, the trough cannot be collected with the morning routine laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose infuses. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. Trough levels would be inaccurate if the specimen is obtained while the drug infuses.

PTS:1DIFifficultREF:p. 756

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 12. Teratogenic drugs should be avoided in which patient population?

1)

Pregnant women

2)

Elderly

3)

Children

4)

Adolescents

ANS: 1

Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects on the embryo or fetus.

PTS:1DIF:EasyREF:p. 756

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

____ 13. A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed?

1)

Supportive

2)

Restorative

3)

Substitutive

4)

Palliative

ANS: 4

Morphine was prescribed for its palliative effectsto relieve pain, a symptom of cancer. Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the body to or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning.

PTS:1DIF:ModerateREF:p. 756

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

____ 14. After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing?

1)

Side effect

2)

Adverse reaction

3)

Toxic reaction

4)

Supportive effect

ANS: 1

Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than side effects. Toxic reactions are dangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions.

PTS:1DIF:ModerateREF:p. 758

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

____ 15. While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first?

1)

Administer epinephrine IM.

2)

Give bolus dose of intravenous fluids.

3)

Stop the infusion of medication.

4)

Prepare for endotracheal intubation.

ANS: 3

The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen to endotracheal intubation and mechanical ventilation may also be necessary.

PTS:1DIFifficultREF:p. 759

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

____ 16. A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing?

1)

Mild adverse reaction

2)

Dose-related adverse reaction

3)

Toxic reaction

4)

Anaphylactic reaction

ANS: 1

Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse reactions are undesired effects that result from known pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration.

PTS:1DIFifficultREF:p. 758

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

____ 17. Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect?

1)

Antagonistic drug interaction

2)

Synergistic drug interaction

3)

Idiosyncratic reaction

4)

Drug incompatibility

ANS: 1

In an antagonistic drug interaction, one drug interferes with the actions of another and decreases the resultant drug effect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a medication. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs.

PTS:1DIF:ModerateREF:p. 759

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis

____ 18. A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug:

1)

Abuse

2)

Misuse

3)

Tolerance

4)

Dependence

ANS: 3

Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus around obtaining and administering the drug.

PTS:1DIF:ModerateREF:p. 760

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

____ 19. Before administering a medication, the nurse must verify the rights of medication administration, which include:

1)

right patient, right room, right drug, right route, right dose, and right time.

2)

right drug, right dose, right route, right time, right physician, and right documentation.

3)

right patient, right drug, right route, right time, right documentation, and right equipment.

4)

right patient, right drug, right dose, right route, right time, and right documentation.

ANS: 4

The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation.

PTS: 1 DIF: Moderate REF: pp. 771-773

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

____ 20. Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen?

1)

After an explanation and written materials, describes the expected actions and adverse reactions of his medication

2)

In 1 week after instructional session, describes the expected actions and adverse reactions of his medications

3)

Follows the treatment plan as prescribed

4)

Experiences no adverse effect from his prescribed treatment plan

ANS: 2

The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patients knowledge deficit. The other options provide no timeline for achieving the goal and are therefore not measurable. Expected outcome statements must be measurable.

PTS:1DIF:Moderate

REF:p. 770; Also requires knowledge of goals, from Chapter 5

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 21. When the nurse enters a patients room to administer a medication, he calls out from the bathroom telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed?

1)

Inform the patient that she will return when he is finished in the bathroom.

2)

Wait outside the bathroom door until the patient is ready for the dose.

3)

Withhold the dose until the next administration time later in the day.

4)

Document that the dose was omitted in the medication administration record.

ANS: 1

The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. Withholding the dose until the next administration time may compromise the patients condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurse should not document a missed dose in the medication administration record.

PTS:1DIF:ModerateREF:pp. 771-772

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 22. Which documentation entry related to PRN medication administration is complete?

1)

6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 110 scale, J. Williams RN

2)

0600 famotidine 20 mg IV given in right hand, S. Abraham RN

3)

9/2/14 0900 levothyroxine 50 mcg PO given

4)

1/16/14 furosemide 40 mg PO given, J. Smith RN

ANS: 1

The longest 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 why the medication was administered. Other options are incomplete.

PTS:1DIF:ModerateREF:pp. 772-773

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 23. A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications?

1)

Request that the prescriber change the order to the IV route.

2)

Administer the medication by the IM route.

3)

Use a needleless syringe to place the medication in the side of the mouth.

4)

Add the dose to a small amount of food or beverage to facilitate swallowing.

ANS: 3

When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patients mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same between oral and IM routes; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary.

PTS:1DIF:Moderate

REF:pp. 774-775; under Special Situations. Inductive reasoning needed to determine correct answer.

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 24. The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug?

1)

Place the drug in the cheek and allow it to dissolve.

2)

Place the drug under the tongue and allow it to dissolve.

3)

Inject the drug superficially into the subcutaneous tissue.

4)

Give the pill and water to the patient for him to swallow the tablet.

ANS: 2

Drugs administered by the sublingual (SL) route should be placed under the patients tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue. Placing the drug into the patients mouth, giving him water, and instructing him to swallow the tablet describe oral administration.

PTS: 1 DIF: Moderate REF: p. 800

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 25. Which action should the nurse take immediately after administering a medication through a nasogastric tube?

1)

Verify correct nasogastric tube placement in the stomach.

2)

Auscultate the abdomen for presence of bowel sounds.

3)

Immediately administer the next prescribed medication.

4)

Flush the tube with water using a needleless syringe.

ANS: 4

The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before administering the medication.

PTS: 1 DIF: Moderate REF: p. 801

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

____ 26. How should the nurse dispose of a contaminated needle after administering an injection?

1)

Place the needle in a specially marked, puncture-proof container.

2)

Recap the needle, and carefully place it in the trash can.

3)

Recap the needle, and place it in a puncture-proof container.

4)

Place the needle in a biohazard bag with other contaminated supplies.

ANS: 1

To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk.

PTS:1DIF:ModerateREF:pp. 785, 819

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

____ 27. The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection?

1)

Ventrogluteal

2)

Vastus lateralis

3)

Deltoid

4)

Dorsogluteal

ANS: 2

The preferred site for IM injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area and the gluteal muscles have not been developed by walking. For children who are walking, the site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for children or adults. The deltoid muscle can be used for small volumes in older children and adults.

PTS: 1 DIF: Moderate REF: p. 787

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 28. 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.

ANS: 4

To relax the vastus lateralis for injection, the nurse should have the patient assume a sitting position or lie flat with his knee slightly flexed. Applying a warm compress, massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging the site can enhance the absorption of medication into the muscle. Applying a warm compress increases circulation to the site, which can also enhance absorption. This action would be performed after the injection and not before.

PTS:1DIF:ModerateREF:p. 834

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

____ 29. The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?

1)

No action is necessary because an extra 5 mg of warfarin is not harmful.

2)

Call the prescriber and ask her to change the order to 10 mg.

3)

Document on the chart that the drug was given and indicate the drug was given in error.

4)

Complete an incident report according to the facilitys policy.

ANS: 4

When a medication error is made, the nurse should first check the patient to assess for negative effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any orders the physician prescribes. Document the drug, the dose, site, route, date, and time in the patients healthcare record but do not document that the drug was given in error. Complete an incident report according to the facilitys policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice.

PTS: 1 DIF: Moderate REF: p. 769

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application

____ 30. The nurse must administer eardrops to an infant. How should she proceed?

1)

Pull the pinna down and back before instilling the drops.

2)

Pull the pinna upward and outward before instilling the drops.

3)

Instill the drops directly; no special positioning is necessary.

4)

Position the patient supine with the head of the bed elevated 30.

ANS: 1

For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward and outward. Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation.

PTS: 1 DIF: Moderate REF: p. 806

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

____ 31. The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance?

1)

Crush time-release capsules to put in his favorite food.

2)

Give medication quickly before he knows what is happening.

3)

Allow the child to eat a frozen pop before receiving the medication.

4)

Mask the flavor of medication in a toddler cup with orange juice.

ANS: 3

The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste of the medication.

To mask bad-tasting medicines, parents can crush pills or empty the contents of a capsule as long as it is not a time-release dose, and mix with soft foods, such as applesauce, hot cereal, or pudding. This is helpful for patients who might aspirate liquids, as well.

If the child is old enough to understand, warn him when a medication has an objectionable taste. Otherwise, his trust might be compromised if he is surprised with a bad taste.

Do not use essential foods in the childs diet (e.g., milk or orange juice) to mask the taste of medications. The child may later refuse a food that he associates with the medicine.

PTS:1DIF:ModerateREF:p. 775

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

____ 32. An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product?

1)

18 gauge

2)

22 gauge

3)

24 gauge

4)

26 gauge

ANS: 1

Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge bores can cause clumping and breakage of the cell, thus leading to reduced effectiveness of the transfusion as well as contributing to fragmented by-product of red blood cell waste.

PTS:1DIF:EasyREF:p. 779

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

True/False

Indicate whether the statement is true or false.

____ 1. At times, patients may self-administer medications when hospitalized.

ANS: T

Occasionally, even in the hospital setting, patients self-administer medications, as their condition permits. For example, a patient admitted with chest pain may keep sublingual nitroglycerin at his bedside so he has quick access should he experience chest pain.

PTS:1DIF:EasyREF:p. 748

KEY:Nursing process: N/A |Client need: PHSI | Cognitive level: Recall

Completion

1. The nurse is drawing up a medication from an ampule. Arrange the following steps in the order in which they should be performed.

A. Use an ampule opener to break ampule neck.

B. Tap the ampule to remove medication trapped in the top of ampule.

C. Invert the ampule, and draw up the medication.

D. Dispose of the top and bottom of the ampule and filter needle in sharps container.

E. Hold the syringe vertically, and tap it to remove air bubbles.

ANS: B, A, C, E, D

Medication must be removed from the ampule neck before breaking the top off the ampule. Otherwise, the dosage may be incorrect. There is no need to remove air bubbles until after the medication is drawn into the syringe. Finally, you would not dispose of the ampule and filter needle until you finish the procedure.

PTS: 1 DIF: Difficult REF: pp. 818-819

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

2. A nurse is administering a medication using a volume-control administration set (e.g., Buretrol, Volutrol). Arrange the following steps in the order in which they would be performed.

A. Inject the ordered medication into the volume-control chamber.

B. Fill the volume-control chamber with the correct amount of intravenous fluid from the primary bag.

C. Cleanse the port on the volume-control chamber.

D. Prime the volume-control tubing.

E. Open the lower clamp and start the infusion at the correct flow rate.

ANS: B, D, C, A, E

You must fill the volume-control chamber before injecting the medication so you can prime the tubing without the risk of wasting medication. You must cleanse the port on the volume-control chamber before injecting the medication into it. The last thing you do is open the clamp and start the infusion.

PTS:1DIFifficultREF:p. 845

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

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