Chapter 35 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 35

Question 1

Type: MCSA

The nurse is preparing to administer a medication that the agency designates as high alert. What action should the nurse take?

1. Ask another registered nurse to verify the medication.

2. Call the pharmacist to check the efficacy of the medication.

3. Decline to administer the medication unless there is a physician present.

4. Request that the nursing supervisor administer the medication.

Correct Answer: 1

Rationale 1: Most health care agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses.

Rationale 2: Although the pharmacy is a valuable resource for nurses, the high-alert designation does not require pharmacy intervention.

Rationale 3: High-alert medications do not require the presence of a physician for administration.

Rationale 4: High-alert medications do not require the presence of a nursing supervisor for administration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Define selected terms related to the administration of medications.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 791

Question 2

Type: MCSA

Why is the nurse writing out the name of the drug morphine sulfate instead of using the abbreviation MS?

1. The hospital has placed MS on its list of do-not-use abbreviations.

2. The Joint Commission requires that the abbreviation MS not be used.

3. Using the abbreviation MS puts the client at risk of medication error.

4. Computerized charting systems will not accept the abbreviation MS.

Correct Answer: 3

Rationale 1: Although the hospital has probably placed MS on its list of do-not-use abbreviations, The Joint Commission does require that the abbreviation not be used.

Rationale 2: The Joint Commission does require that the abbreviation not be used; however ,client safety is the primary reason.

Rationale 3: The best answer is that using the abbreviation MS puts the client at risk of medication error.

Rationale 4: Although some computerized charting systems will not accept the abbreviation MS, the best reason is for client safety.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe legal aspects of administering medications.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 760

Question 3

Type: MCSA

The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache?

1. Yes, as Tylenol is used both for fever and headache.

2. No, not unless the client also has a temperature over 101F.

3. Yes, but the nurse should document the reason why the medication was administered as a temperature elevation.

4. Yes, because the medication is available over the counter, an order is not required.

Correct Answer: 2

Rationale 1: In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the clients headache.

Rationale 2: In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the clients headache.

Rationale 3: The nurse should never document false information in regard to medication administration.

Rationale 4: The fact that this is an over-the-counter medication and is used both for fever and headache is not pertinent to the nurses decision.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe legal aspects of administering medications.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 773

Question 4

Type: MCSA

The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take?

1. Administer the medication as it was ordered.

2. Check to see if previous shift nurses gave the medication.

3. Collaborate with the prescriber about the order.

4. Administer only the standard dose of the medication.

Correct Answer: 3

Rationale 1: Administering the dose as ordered may harm the client.

Rationale 2: The fact that previous nurses gave the medication as ordered does not make it the correct action.

Rationale 3: When the nurse has doubts about the correctness of a medication or medication dose for a specific client, collaboration with the prescriber is necessary. The nurse is legally and ethically responsible for all actions taken, including medication administration.

Rationale 4: The nurse cannot change the amount of medication to give without collaborating with the prescriber.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11. State the rights to accurate medication administration.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 769

Question 5

Type: FIB

The client has required 2 sublingual nitroglycerine tablets that are gr 1/150 per tablet. How many mg of nitroglycerine did the client receive?

Standard Text: Record your answer.

Correct Answer: 0.8 mg or 800 mcg

Rationale: The client received gr 2/150 of NTG. There are 60 mg in 1 grain. To convert, multiply 2/150 x 60 = 120/150 = 0.8 mg or 800 mcg. 

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 9. Describe four formulas for calculating drug dosages.

MNL Learning Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately.

Page Number: 763

Question 6

Type: MCSA

The nurse is preparing to administer a medication to a 6-year-old client. What is the nurses priority action?

1. Administer the exact dosage as ordered.

2. Give the dosage supplied by the pharmacy.

3. Verify that the dosage is within the safe range for this child.

4. Administer no more than one-half of the safe adult dosage.

Correct Answer: 3

Rationale 1: This dose should be compared to the standard dose listed in a reputable drug reference book.

Rationale 2: Although prescribers and pharmacists are also responsible to figure the correct dose, the nurse who administers the dose is the last possible person to prevent a medication error. The nurse has the final responsibility to ensure that the dose ordered and dose supplied are correct for the client.

Rationale 3: The priority action is to verify that the dosage is within the safe range for this child. This verification can be done by figuring the dose per kilogram of body weight or by use of a nomogram.

Rationale 4: This dose may be more or less than one-half the adult dosage.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe four formulas for calculating drug dosages.

MNL Learning Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately.

Page Number: 764

Question 7

Type: MCSA

During the process of administering medications, the nurse checks the name band for the clients name. What should be this nurses next action?

1. Administer the medication as ordered.

2. Initial the MAR that the medication will be given.

3. Double check the clients identification using a second method.

4. Educate the client regarding the medication to be given.

Correct Answer: 3

Rationale 1: This nurse should employ a second method to verify the clients identification.

Rationale 2: The MAR will be initialed after the medication has been given.

Rationale 3: The Joint Commissions National Safety Goals require a two-step check of client identification prior to the administration of medications. This nurse should employ a second method to verify the clients identification.

Rationale 4: Once the nurse has verified client identification, the nurse should educate the client regarding the medication to be given.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. List six essential steps to follow when administering medication.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 771

Question 8

Type: MCSA

The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old client. What strategy should this nurse plan?

1. Give the medication in orange juice or milk to mask the taste.

2. Tell the child that the medication tastes good.

3. Ask the parents how they give medications at home.

4. Get another nurse to assist by holding the client down.

Correct Answer: 3

Rationale 1: Medication should not be placed in essential foods such as orange juice or milk, as the child may develop an aversion to the food related to the taste of the medication.

Rationale 2: Being untruthful about any interventions may cause the client to lose trust in the nurse.

Rationale 3: Parents are a very good source of ideas for caring for their child, and their input should be sought when performing tasks such as medication administration.

Rationale 4: Having a second nurse hold the client down to administer the medication is an unnecessary use of force and will frighten the child.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. List six essential steps to follow when administering medication.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 774

Question 9

Type: MCSA

The nurse is caring for a team of four clients who are seriously ill. One of the clients has just received a new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client?

1. Have the UAP assess for any unexpected effects from the medication.

2. Tell the UAP to teach the clients family what to expect from the medication.

3. Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects.

4. Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse.

Correct Answer: 4

Rationale 1: The UAP does not have the skills or legal responsibility to assess the client.

Rationale 2: It is the nurses responsibility to teach the client or family about the medications.

Rationale 3: The nurse should not expect that the UAP can determine from the drug reference book what drug actions and possible side effects are pertinent to this client.

Rationale 4: The nurse should give the UAP specific instructions about what drug actions or side effects should be reported to the nurse. The UAP does not have the skills or legal responsibility to assess the client, but can collect data to report to the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21. Recognize when it is appropriate to delegate medication administration to unlicensed assistive personnel.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 775

Question 10

Type: MCSA

The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has been crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form. How should the nurse administer these medications?

1. Flush the tube, mix the crushed tablet and the capsule powder into the two liquids for administration, and follow by flushing the tube.

2. Mix the crushed tablet and capsule powder in warm water and administer. Flush the tube and administer the mixed liquids.

3. Flush the tube with the mixed liquids first, then administer the crushed tablet and capsule powder mixed in cold water.

4. Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration.

Correct Answer: 4

Rationale 1: Mixing medications together may result in a chemical reaction that occludes the tube.

Rationale 2: Mixing medications together may result in a chemical reaction that occludes the tube.

Rationale 3: Mixing medications together may result in a chemical reaction that occludes the tube.

Rationale 4: When giving medication via a nasogastric or gastric tube, the nurse should individually prepare and administer the medications, flushing the tube before and after each administration. Failure to flush the tube adequately is the leading cause of tube occlusion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 14. Outline the steps required for nasogastric and gastrostomy tube medication administration.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 780

Question 11

Type: MCSA

At which point of preparing medication from an ampule does the nurse anticipate using a filter needle?

1. Filter needles are not used for this preparation.

2. When drawing the medication from the ampule.

3. When administering the medication to the client.

4. Both for drawing up the medication and for administering the medication.

Correct Answer: 2

Rationale 1: A filter needle is used to draw medication from an ampule.

Rationale 2: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid.

Rationale 3: If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle.

Rationale 4: The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. The filter needle is then changed to a regular needle prior to administering the liquid to the client. If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16. Verbalize the steps used in: a. Preparing medications from ampules.

MNL Learning Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 785

Question 12

Type: MCSA

The client is to receive an intramuscular injection of a medication that is supplied in a 2-mL cartridge and a second medication that is supplied in a vial. The total amount to be administered of these medications exceeds the volume of the cartridge by 0.5 mL. How should the nurse proceed?

1. Administer the cartridge medication in one injection and the vial medication in a separate injection.

2. Call the pharmacy for advice on administering these medications.

3. Draw both of the medications up into a syringe for administration.

4. Add as much of the vial medication to the cartridge as possible prior to injection, giving the balance in a separate injection.

Correct Answer: 3

Rationale 1: Giving two separate injections, no matter how the medication is divided, should be avoided if possible.

Rationale 2: There is no need for the nurse to consult the pharmacy for this standard technique.

Rationale 3: When the total amount of medication to administer exceeds the volume of the cartridge, the medication is drawn up into a syringe and is administered.

Rationale 4: Giving two separate injections, no matter how the medication is divided, should be avoided if possible.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 16. Verbalize the steps used in: c. Mixing medications in one syringe.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 791

Question 13

Type: MCSA

During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the clients skin. How should the nurse proceed?

1. Recognize that this is an expected finding in a properly administered intradermal injection.

2. Withdraw the needle, prepare a new injection, and start again.

3. Insert the needle further into the skin at a deeper angle.

4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb.

Correct Answer: 1

Rationale 1: Intradermal injections are given at a very shallow angle so that the medication is delivered into the area between the dermal layers. When properly given, the outline of the needle bevel will be visible prior to injection of the fluid.

Rationale 2: There is no need to withdraw the needle and start again.

Rationale 3: Inserting the needle further into the skin and at a deeper angle would result in delivery of the fluid into the subcutaneous tissues.

Rationale 4: The needle is inserted with the bevel up.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes:

a. Intradermal.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 792

Question 14

Type: MCSA

The nurse has just injected insulin subcutaneously into the clients abdomen. What action should the nurse take at this point?

1. Massage the site to encourage absorption.

2. Leave the needle embedded in the clients skin for 5 seconds after administration.

3. Remove the needle rapidly by pulling it quickly from the skin.

4. Cover the injection site with a pressure dressing for at least 15 minutes or until the bleb disappears.

Correct Answer: 2

Rationale 1: Massage is contraindicated for most medications because it alters the delivery rate from the tissues.

Rationale 2: The American Diabetes Association recommends leaving the needle embedded in the clients skin for 5 seconds after injection of medication, particularly insulin. This allows for complete delivery of the dose.

Rationale 3: The needle should be removed slowly and smoothly to minimize pain for the client.

Rationale 4: Bleeding rarely occurs after subcutaneous injection, but short application of manual pressure (13 minutes) should cause bleeding to stop. There is no need for a pressure dressing for 15 minutes. Subcutaneous injections do not result in bleb formation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes:

b. Subcutaneous.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 796

Question 15

Type: MCSA

The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection?

1. The same site

2. The deltoid

3. The left ventrogluteal

4. The rectus femoris

Correct Answer: 3

Rationale 1: The same site should not be used because this is not enough time for tissue recovery.

Rationale 2: The deltoid site will not accept 2.5 mL of medication.

Rationale 3: Of the options given, the best choice is the left ventrogluteal. This is a site that will accept 2.5 mL of medication, and using the opposite site from the last injection will allow the first site time for recovery.

Rationale 4: The rectus femoris site is generally used only for self-injection of medication and is a painful site for medication administration.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 798

Question 16

Type: MCSA

While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take?

1. Pull the needle out 1/4 inch and inject the medication.

2. Inject the medication as planned.

3. Notify the physician immediately.

4. Discard the medication and start over.

Correct Answer: 4

Rationale 1: Simply pulling out the needle 1/4 inch does not guarantee that the needle point is not in a vessel, and the presence of blood in the syringe prevents checking the new site.

Rationale 2: Blood return in the syringe barrel after aspiration indicates a strong probability that the needle tip is in a blood vessel. Injection of medication would then be intravenous, not intramuscular.

Rationale 3: There is no need to notify the physician of this event.

Rationale 4: The nurse should discard the medication and start over with new medication and a new syringe.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 18. Verbalize the steps used in administering parenteral medications by the following routes: c. Intramuscular

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 801

Question 17

Type: MCSA

The nurse is adding medication to an existing intravenous setup. Which nursing action is indicated?

1. Close the infusion clamp.

2. Ensure that the IV bag is full prior to adding medication.

3. Do not remove the IV bag from the pole.

4. Briskly shake the IV bag after injecting the medication.

Correct Answer: 1

Rationale 1: The nurse must close the infusion clamp prior to adding medication to an existing IV bag. Closing the clamp prevents the medication from inadvertently going directly down the tubing and into the client.

Rationale 2: Medication is frequently added to IV bags that are less than completely full. The nurse must make a determination of whether the bag contains enough fluid to dilute the medication to the desired strength.

Rationale 3: The bag can be taken from the IV pole for mixing.

Rationale 4: The bag should receive a gentle rotation, not brisk shaking, to mix the medication and the fluid.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19. Verbalize the steps used in: a. Adding medications to intravenous fluid containers.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 805

Question 18

Type: MCSA

Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken?

1. Discontinue this infiltrated lock and restart another site for medication administration.

2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration.

3. Reinsert the needle into the lock and aspirate using more pressure.

4. Pull the intravenous catheter out 1/8 inch and attempt aspiration.

Correct Answer: 2

Rationale 1: Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site.

Rationale 2: Although the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication.

Rationale 3: Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return.

Rationale 4: Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19. Verbalize the steps used in: b. Administering intravenous medications using IV push.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 809

Question 19

Type: MCSA

While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point?

1. Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway.

2. Notify the pharmacy and request a new, unopened tube of ointment.

3. Have a second licensed nurse witness the waste and sign the chart.

4. Continue to squeeze the tube until a clear line of ointment has been discarded from the tip.

Correct Answer: 1

Rationale 1: The nurse should administer the eye ointment as ordered, as the first bead of ointment is considered contaminated and should always be discarded.

Rationale 2: There is no need to notify the pharmacy for a new tube of ointment.

Rationale 3: There is no need to have the wastage witnessed by another nurse.

Rationale 4: It is necessary to discard only the first bead of ointment, not an entire line.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: b. Ophthalmic

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 814

Question 20

Type: MCSA

The nurse is preparing to administer eardrops to a 6-year-old client. What nursing action is correct?

1. Pull the earlobe down and back to straighten the ear canal.

2. Insert the tip of the applicator into the ear canal.

3. Put the eardrops in the refrigerator for 10 minutes prior to administration.

4. Press gently on the tragus of the ear a few times after administration.

Correct Answer: 4

Rationale 1: After age 3, the pinna of the ear should be pulled up and back to straighten the ear canal.

Rationale 2: The tip of the eardrop applicator should not be placed into the ear canal, but should be held just above the canal so that the drops can fall onto the side of the canal.

Rationale 3: Eardrops should be warmed prior to administration, not cooled.

Rationale 4: The nurse should press gently but firmly on the tragus of the ear after eardrops are administered in order to direct the drops into the ear canal.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: c. Otic

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 816

Question 21

Type: MCSA

While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the clients bed linens. How can the nurse avoid this situation with the patch now being applied?

1. Shave the area where the patch is being applied.

2. Place a heating pad over the area where the patch is applied for 10 minutes after application.

3. Run a finger around the adhesive edges of the new patch before placing it on the clients skin.

4. Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin.

Correct Answer: 4

Rationale 1: If hair is a problem in keeping the patch on, choose a less hairy site for application or clip (do not shave) the hair.

Rationale 2: Placement of a heating pad is contraindicated, as the heat could increase circulation and the rate of absorption.

Rationale 3: Avoid touching the adhesive edges of the patch prior to placing it on the skin.

Rationale 4: In order to affix the patch firmly to the clients skin, press firmly over the patch with the palm of the hand for about 10 seconds after application.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: a. Dermatologic

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 812

Question 22

Type: MCSA

The nurse is preparing a small amount of medication for oral administration. Which nursing action is essential?

1. Draw up the medication in a syringe with a large-gauge needle.

2. Measure the medication at the top of the meniscus.

3. Label the syringe with the medication name, amount, and route.

4. Dilute the medication with water before measuring.

Correct Answer: 3

Rationale 1: If a regular syringe is used to draw up the medication, the needle should be discarded. A syringe with a needle might also indicate that the medication is to be given parenterally and cause a medication route error.

Rationale 2: If medications are measured in a cup, the correct measurement is at the bottom of the meniscus.

Rationale 3: When measuring medication in a syringe, a label must be attached indicating the name of the medication, the amount, and the route. This labeling is essential to prevent the medication from being given via the wrong route.

Rationale 4: Medication might be diluted after measuring, but dilution before measuring would impact the dosage of the medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 13. Verbalize the steps used in administering oral medications safely.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 777

Question 23

Type: MCSA

A client diagnosed with diabetes asks the nurse about reusing insulin syringes. Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client has financial difficulties. What instruction should the nurse give this client?

1. The American Diabetes Association advises that syringes are for single use only.

2. In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull.

3. Only people who practice good personal hygiene can reuse syringes.

4. All clients are different, but I advise you to use a new syringe for each injection.

Correct Answer: 4

Rationale 1: This is not true; the American Diabetes Association indicates that syringes can be reused.

Rationale 2: This client does not meet the criteria for suggesting the reuse of syringes.

Rationale 3: The nurse should not directly confront the client with the statement about personal hygiene, as that would damage the nurseclient relationship.

Rationale 4: Although the American Diabetes Association does indicate that syringes can be reused, that suggestion is not made to people who have poor personal hygiene, acute concurrent illness, open wounds on the hands, or decreased resistance to infection. In this case, the nurse has assessed that this client has poor hygiene and has difficulty with fine motor skills. The best answer is to suggest that this client use a new syringe for each injection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17. Identify the sites used for: b. Subcutaneous injection.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 796

Question 24

Type: MCSA

The client who regularly uses a metered-dose inhaler four times a day tells the nurse that it is difficult to tell when the canister is empty. What instruction should the nurse give this client?

1. Place the canister in a bowl of water. If the canister floats, it is not empty.

2. When you get a new canister, divide the number of puffs that is listed on the label by four. That will tell you how many days the canister will last.

3. You can tell that the canister is empty when you can no longer smell the medication when you activate the plunger.

4. When you feel like you are no longer getting maximum effect from the medication, your canister is empty.

Correct Answer: 2

Rationale 1: The old method of floating the canister in water is not accurate, as there may be propellant left in the canister after the medication is all dispensed.

Rationale 2: The best way to track the number of puffs left in a canister is to start with the new canister, dividing the number of puffs listed on the label by the number of puffs taken each day.

Rationale 3: Being able to smell the medication is not an indication of the amount left in the canister.

Rationale 4: Waiting until there is lack of maximum effect from the medication may put the client at risk for respirator illness exacerbation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 822

Question 25

Type: MCSA

The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for a bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding the dosage schedule for these two medications?

1. Always use the corticosteroid inhaler first.

2. Use the bronchodilator first.

3. It makes no difference which inhaler is used first.

4. Use the inhalers on alternate days, not on the same day.

Correct Answer: 2

Rationale 1: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs.

Rationale 2: These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs.

Rationale 3: The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs.

Rationale 4: These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: g. Respiratory inhalation

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 823

Question 26

Type: MCSA

The nurse is planning to administer medications to a new client. What is the nurses greatest priority in administering these medications?

1. Be certain the medications are given within 15 minutes of the time they are scheduled.

2. Before giving the medications, know what the intended effects are for this client.

3. Assess the clients knowledge of the action of the medications.

4. Document the administration accurately so the reimbursement is correct.

Correct Answer: 2

Rationale 1: This is important but not the greatest priority.

Rationale 2: The greatest priority is to understand the intended effects of the medication for this client. The nurse should never do anything to or for a client without knowing the intended effect.

Rationale 3: This is important but not the greatest priority.

Rationale 4: This is important but not the greatest priority.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Describe actions of drugs on the body.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 752

Question 27

Type: MCSA

A client who has been prescribed a narcotic for chronic back pain is demonstrating signs of withdrawal. The nurse identifies these symptoms as being

1. physical dependence.

2. psychological dependence.

3. plateau.

4. drug allergy.

Correct Answer: 1

Rationale 1: Physiological dependence is due to biochemical changes in body tissues, especially the nervous system. These tissues come to require the substance for normal functioning. A dependent person who stops using the drug experiences withdrawal symptoms.

Rationale 2: Psychological dependence is emotional reliance on a drug to maintain a sense of well-being, accompanied by feelings of need or cravings for that drug. There are varying degrees of psychological dependence, ranging from mild desire to craving and compulsive use of the drug.

Rationale 3: Plateau is a maintained concentration of a drug in the plasma during a series of scheduled doses.

Rationale 4: A drug allergy is an immunologic reaction to a drug. When a client is first exposed to a foreign substance, the body might react by producing antibodies. A client can react to a drug in the same manner as an antigen and thus develop symptoms of an allergic reaction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe actions of drugs on the body.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 754

Question 28

Type: MCSA

A client is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics will be affected in this client?

1. Absorption

2. Distribution

3. Biotransformation

4. Excretion

Correct Answer: 3

Rationale 1: Absorption is the process by which a drug passes into the bloodstream.

Rationale 2: Distribution is the transportation of a drug from its site of absorption to its site of action.

Rationale 3: Biotransformation, also called detoxification or metabolism, is a process by which a drug is converted to a less active form. Most biotransformation takes place in the liver. Biotransformation can be altered if a person has an unhealthy liver.

Rationale 4: Excretion is the process by which metabolites and drugs are eliminated from the body. Most drug metabolites are eliminated by the kidneys via the urine.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe actions of drugs on the body. 4. Identify factors affecting medication action.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 755

Question 29

Type: MCSA

The nurse is administering a medication to a client as prescribed in order to maintain a specific amount of the medication in the clients bloodstream at all times. The nurse is ensuring that which action is being maintained for this client?

1. Peak plasma level

2. Drug half-life

3. Onset of action

4. Plateau

Correct Answer: 4

Rationale 1: Peak plasma level is the highest plasma level achieved by a single dose when the elimination rate of the drug equals the absorption rate.

Rationale 2: Drug half-life is the time required for the elimination process to reduce the concentration of the drug to one-half of what it was at initial administration.

Rationale 3: Onset of action is the time after administration when the body initially responds to the drug.

Rationale 4: Plateau is when a concentration of a drug is maintained in the clients plasma through a series of scheduled doses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe actions of drugs on the body. 4. Identify factors affecting medication action.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 755

Question 30

Type: MCMA

The nurse determines that the effectiveness of a medication is not as great when provided to female clients as it is with male clients. The nurse suspects that this difference in effectiveness is because of which factor?

Standard Text: Select all that apply.

1. Occupation

2. Hormones

3. Fat amount

4. Physical activity status

5. Fluid level

Correct Answer: 2, 3, 5

Rationale 1: Differences in the way men and women respond to drugs are not chiefly related to occupation.

Rationale 2: Differences in the way men and women respond to drugs are chiefly related to hormone levels.

Rationale 3: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fat.

Rationale 4: Differences in the way men and women respond to drugs are not chiefly related to physical activity status.

Rationale 5: Differences in the way men and women respond to drugs are chiefly related to the distribution of body fluid.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify factors affecting medication action.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 757

Question 31

Type: MCMA

A client is prescribed an oral medication. When reviewing this medication, the nurse realizes it might not be the route of choice for this client because the client is experiencing

Standard Text: Select all that apply.

1. nausea.

2. anxiety.

3. vomiting.

4. pain from cuts and abrasions.

5. irritated gastric mucosa.

Correct Answer: 1, 3, 5

Rationale 1: Oral medications are inappropriate for a client who is nauseated.

Rationale 2: Oral medications are appropriate for the client experiencing anxiety.

Rationale 3: Oral medications are inappropriate for a client who is vomiting

Rationale 4: Oral medications are appropriate for the client experiencing pain from cuts and abrasions.

Rationale 5: Oral medications are inappropriate for a client with irritated gastric mucosa.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe actions of drugs on the body. 5. Describe various routes of medication administration.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 758

Question 32

Type: MCMA

A client is prescribed a medication to be administered through the parenteral route. The nurse would expect that this medication will be provided through which method?

Standard Text: Select all that apply.

1. Subcutaneous injection

2. Intramuscular injection

3. The oral route

4. Intradermal injection

5. Intravenous infusion

Correct Answer: 1, 2, 4, 5

Rationale 1: Subcutaneous injection is considered a parenteral route of administration.

Rationale 2: Intramuscular injection is considered a parenteral route of administration.

Rationale 3: The oral route is not a parenteral route of administration.

Rationale 4: Intradermal injection is considered a parenteral route of administration.

Rationale 5: Intravenous injection is considered a parenteral route of administration.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15. Identify equipment required for parenteral medications..

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 759

Question 33

Type: MCMA

The nurse is reviewing a new medication order for a client, and determines that the order is incomplete when which element is missing?

Standard Text: Select all that apply.

1. Clients address

2. Dispensing instructions for the pharmacist

3. Name of the medication

4. Dosage

5. Route of administration

Correct Answer: 3, 4, 5

Rationale 1: The clients address is part of a prescription but not of a medication order.

Rationale 2: Dispensing instructions for the pharmacist are a part of a prescription but not of a medication order.

Rationale 3: The name of the medication is an essential part of the medication order.

Rationale 4: The dosage is an essential part of the medication order.

Rationale 5: The route of administration is an essential part of the medication order.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify essential parts of a medication order.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 761

Question 34

Type: MCMA

A client tells the nurse that the pharmacy will not fill a prescription that was written by the physician. Upon closer examination, what should the nurse determine is missing from the prescription?

Standard Text: Select all that apply.

1. Rx symbol

2. Clients diagnosis

3. Clients Social Security number

4. Dispensing instructions for the pharmacist

5. Number of refills

Correct Answer: 1, 4, 5

Rationale 1: The Rx symbol is to be written on a prescription.

Rationale 2: The clients diagnosis is not part of a prescription.

Rationale 3: The clients Social Security number is not part of a prescription.

Rationale 4: The dispensing instructions for the pharmacist are part of a prescription.

Rationale 5: The number of refills must be provided on a prescription.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify essential parts of a medication order.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 761

Question 35

Type: MCSA

A client has a new order for a medication that does not have a termination date. The nurse would place this medication order under which classification on the clients medication administration record?

1. Standing

2. PRN

3. STAT

4. Single

Correct Answer: 1

Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely.

Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurses judgment, the client needs it.

Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once.

Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. List examples of various types of medication orders.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 760

Question 36

Type: MCSA

A clients status is deteriorating, and the physician prescribes a medication to be administered immediately one time. The nurse would contact the pharmacy and identify this medication order as being of which type?

1. Standing

2. PRN

3. STAT

4. Single order

Correct Answer: 3

Rationale 1: A standing order might not have a termination date. This medication may be provided to the client indefinitely.

Rationale 2: A PRN order or an as-needed order permits the nurse to provide the client with the medication when, in the nurses judgment, the client needs it.

Rationale 3: A STAT order indicates that the medication is to be provided immediately and only once.

Rationale 4: A single order or a one-time order indicates that the medication is to be provided only once.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. List examples of various types of medication orders.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 760

Question 37

Type: MCSA

While hospitalized, a client was receiving 15 ml of an oral medication three times a day. When providing discharge instructions, the nurse should teach the client to take how much of this medication at home?

1. 2 teaspoons

2. 1 teaspoon

3. 2 tablespoons

4. 1 tablespoon

Correct Answer: 4

Rationale 1: In the household measurement system, 2 teaspoons is equivalent to 810 ml in the metric system.

Rationale 2: In the household measurement system, 1 teaspoon is equivalent to 45 ml in the metric system.

Rationale 3: In the household measurement system, 2 tablespoons is equivalent to 30 ml in the metric system.

Rationale 4: In the metric system, 15 ml is equal to 1 tablespoon in the household measurement system.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe four formulas for calculating drug dosages.

Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately.

Page Number: 764


Question 38

Type: MCMA

While reviewing a medication order, the nurse determines that it is written using the metric system. What did the nurse observe to come to this conclusion about the medication order?

Standard Text: Select all that apply.

1. Number of ounces

2. Number of drams of the solution

3. Number of milligrams of the medication

4. Number of grains of the medication

5. Number of milliliters of the solution

Correct Answer: 3, 5

Rationale 1: Ounces are a measurement in the household system.

Rationale 2: Drams are a measurement in the apothecaries system.

Rationale 3: Milligrams are a measurement in the metric system.

Rationale 4: Grains are a measurement in the apothecaries system.

Rationale 5: Milliliters are a measurement in the metric system.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. State systems of measurement that are used in the administration of medications.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 762

Question 39

Type: MCSA

The nurse is providing medications to a client. After identifying the client, the nurse should take which action?

1. Inform the client as to the intended action of the medication.

2. Administer the drug.

3. Document that the drug was provided.

4. Evaluate the effectiveness of the drug.

Correct Answer: 1

Rationale 1: After identifying the client, the nurse should next instruct the client as to the intended action of the medication.

Rationale 2: The medication is administered after the client has been instructed about the medication.

Rationale 3: Documentation occurs after the medication has been given.

Rationale 4: The medication is evaluated for effectiveness after a period of time has elapsed after administering the medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the rights to accurate medication administration.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 772

Question 40

Type: MCSA

Before administering a medication to a client, the nurse checks the clients pulse, blood pressure, and laboratory values. The nurse is performing which right of medication administration?

1. Medication

2. Assessment

3. Route

4. Dose

Correct Answer: 2

Rationale 1: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right medication.

Rationale 2: Some medications require specific assessments prior to administration, such as blood pressure, pulse, or laboratory values. Medication orders can include specific parameters for administration, so these assessments must be done before administering.

Rationale 3: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right route.

Rationale 4: The nurse would not need to assess blood pressure, pulse, or laboratory values to determine the right dose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the rights to accurate medication administration.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 773

Question 41

Type: MCMA

The nurse is preparing medications for a client. What should the nurse do to ensure that the correct medication is provided to the client?

Standard Text: Select all that apply.

1. Make sure it is the right client.

2. Make sure it is the right medication.

3. Make sure it is the right dose.

4. Make sure it is the right route.

5. Make sure it is for the right diagnosis.

Correct Answer: 1, 2, 3, 4

Rationale 1: The right client is one of the rights of medication administration.

Rationale 2: The right medication is one of the rights of medication administration.

Rationale 3: The right dose is one of the rights of medication administration.

Rationale 4: The right route is one of the rights of medication administration.

Rationale 5: The right diagnosis is not one of the rights of medication administration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. List six essential steps to follow when administering medication. 11. State the rights to accurate medication administration.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 773

Question 42

Type: MCSA

The nurse is concerned that an older client is experiencing an adverse effect from a prescribed medication. What did the nurse assess to make this clinical decision?

1. Altered memory

2. Altered organ responsiveness

3. Decreased manual dexterity

4. Decreased visual acuity

Correct Answer: 2

Rationale 1: Altered memory will not cause an adverse drug effect.

Rationale 2: Altered quality of organ responsiveness, resulting in adverse effects becoming pronounced before therapeutic effects are achieved, is one effect of medications on the older client.

Rationale 3: Decreased manual dexterity will not cause an adverse drug effect.

Rationale 4: Decreased visual acuity will not cause an adverse drug effect.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12. Describe the physiological changes in older adults that alter medication administration and effectiveness.

Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 774

Question 43

Type: MCMA

The nurse is concerned that an older client will have difficulty self-administering medications. What did the nurse assess that caused this concern?

Standard Text: Select all that apply.

1. Eats several servings of fruits and vegetables each day

2. Altered memory

3. Decreased visual acuity

4. Decreased manual dexterity

5. Limits red meat in the diet

Correct Answer: 2, 3, 4

Rationale 1: Eating several servings of fruits and vegetables each day will not influence the older clients ability to self-administer medications.

Rationale 2: Altered memory is one physiological change associated with aging that influences medication administration.

Rationale 3: Decreased visual acuity is one physiological change associated with aging that influences medication administration.

Rationale 4: Decreased manual dexterity is one physiological change associated with aging that influences medication administration.

Rationale 5: Limiting red meat in the diet will not influence the older clients ability to self-administer medications.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 12. Describe the physiological changes in older adults that alter medication administration and effectiveness.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 774

Question 44

Type: MCSA

The nurse is preparing to administer a subcutaneous injection to a client. When selecting the needle, the nurse should choose one with a

1. small gauge number.

2. long shaft.

3. long bevel.

4. short bevel.

Correct Answer: 3

Rationale 1: Needles with small gauge numbers are used for viscous medications. For subcutaneous injections, a larger gauge number should be used.

Rationale 2: Long shafts are used for intramuscular injections.

Rationale 3: Longer bevels provide the sharpest needles, and cause less discomfort. They are commonly used for subcutaneous and intramuscular injections.

Rationale 4: Short bevels are used for intradermal and IV injections because a long bevel can become occluded if it rests against the side of a blood vessel.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. b. Subcutaneous

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 783

Question 45

Type: MCSA

An adult client is prescribed the hepatitis B vaccination. The nurse will administer this medication through which site?

1. Dorsogluteal

2. Rectus femoris

3. Vastus lateralis

4. Deltoid

Correct Answer: 4

Rationale 1: Using the dorsogluteal site can lead to nerve damage, and is not recommended as a site for intramuscular injections.

Rationale 2: The rectus femoris muscle is used only occasionally for intramuscular injections because it is painful.

Rationale 3: The vastus lateralis muscle is recommended for infants younger than 1 year of age, although it can be used for clients of all ages.

Rationale 4: The deltoid muscle is not used often for intramuscular injections because it is a relatively small muscle and is very close to the radial nerve and radial artery. It is sometimes considered for use in adults because of rapid absorption from the deltoid area, but no more than 1 mL of solution can be administered. This site is recommended for the administration of hepatitis B vaccine in adults.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 17. Identify the sites used for: c. Intramuscular injection.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 800

Question 46

Type: MCMA

The nurse has provided an otic medication to a client. What should the nurse document about this medications administration?

Standard Text: Select all that apply.

1. Name of the drug

2. The strength

3. The appetite of the client

4. The number of drops

5. The response of the client

Correct Answer: 1, 2, 4, 5

Rationale 1: When documenting after providing an otic medication, the nurse should include the name of the drug.

Rationale 2: When documenting after providing an otic medication, the nurse should include the strength.

Rationale 3: When documenting after providing an otic medication, the nurse does not need to include the clients appetite.

Rationale 4: When documenting after providing an otic medication, the nurse should include the number of drops.

Rationale 5: When documenting after providing an otic medication, the nurse should include the response of the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 20. Verbalize the steps used in administering the following topical medications: c. Otic. 22. Demonstrate appropriate documentation and reporting of medication administration skills.

Outcome: 4.14.4. Implement the nursing process in the administration of medications.

Page Number: 817

Question 47

Type: MCSA

A client is prescribed a new medication. The pharmacy notifies the nurse that the dosage is outside of route prescribing limits. The nurse is unable to reach the prescribing physician about the order. What should the nurse do?

1. Give the medication to the client as prescribed.

2. Withhold the medication.

3. Give one-half of the medication dose prescribed.

4. Administer the medication through the oral route.

Correct Answer: 2

Rationale 1: The nurse should not give the medication as prescribed, as the pharmacy has identified that the dose prescribed is outside of dosing limits.

Rationale 2: If the primary care provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the medication.

Rationale 3: The nurse should not give the client one-half of the medication dose prescribed, as this is outside of the nurses licensure.

Rationale 4: The nurse should not administer the medication through the oral route, as this might not be the best route for the medication and changing the route is outside of the nurses licensure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe legal aspects of administering medications.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 762

Question 48

Type: FIB

A client weighing 220 lbs. is prescribed to receive 25 mg/kg of a medication, divided over 4 equal doses. How many mg of the medication should the nurse provide for each dose?

Standard Text: Round to the nearest whole number.

Correct Answer: 625 mg

Global Rationale: First determine the clients weight in kg by dividing the weight in lbs. by 2.2, or 220/2.2 = 100 kg. Then multiply the prescribed dose of 25 mg x 100 kg = 2500 mg. Then divide the total mg dose by 4, or 2500/4 = 625 mg. The nurse should provide 625 mg of the medication for each dose.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe four formulas for calculating drug dosages.

Outcome: 4.14.2. Utilize the four methods to calculate drug dosages accurately.

Page Number: 764, 765

Question 49

Type: MCMA

The nurse is instructing a new mother on the method to provide a newly prescribed medication to her 2-month-old infant. What should the nurse include in this teaching?

Standard Text: Select all that apply.

1. Mix the medication into the babys formula.

2. Use a nipple so the baby can suck the medication.

3. Use a syringe or dropper to provide the medication.

4. Place a small amount of the medication along the side of the babys cheek.

5. Prepare twice the amount of medication prescribed because the baby will spit out half of it.

Correct Answer: 2, 3, 4

Rationale 1: Never mix medications into foods that are essential, as the infant may associate the food with an unpleasant taste and refuse that food in the future. Never mix medications with formula.

Rationale 2: Oral medications can be provided to a baby with the use of a nipple so that the baby sucks the medication.

Rationale 3: Oral medications can be provided to a baby with a syringe or dropper.

Rationale 4: Oral medications can be provided to a baby by placing a small amount of liquid medication along the inside of the babys cheek and waiting for the infant to swallow.

Rationale 5: The mother should never be instructed to provide the baby with twice the amount of medication that is prescribed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe various routes of medication administration.

Outcome: 4.14.3. Apply the correct principles and procedures for safe administration of medications to clients.

Page Number: 779

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