Chapter 8: Percutaneous Administration My Nursing Test Banks

Chapter 8: Percutaneous Administration

Test Bank

MULTIPLE CHOICE

1. A patient has an infected wound with large amounts of drainage. Which type of dressing would the nurse use?

a.

Telfa

b.

OpSite

c.

DuoDerm

d.

AlgiDERM

ANS: D

AlgiDERM is manufactured from seaweed and is recommended for infected wounds because it is an exudate absorber. Telfa and OpSite do not absorb exudates. DuoDerm is for light to moderate wound drainage. According to the manufacturer, it does absorb exudates, but it is best for wounds with moderate drainage.

DIF: Cognitive Level: Comprehension REF: p. 105 OBJ: 1

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

2. Where would the nurse apply nitroglycerin ointment on a male patient?

a.

The same site that was previously used

b.

A hairy area of the chest

c.

The upper arm

d.

The back of the knee

ANS: C

Any area without hair may be used. Most people prefer the chest, flank, or upper arm areas. Sites should be rotated. The back of the knee is not suitable for applying medication because of the joint motion and difficulty of keeping a dressing in place.

DIF: Cognitive Level: Comprehension REF: p. 107 OBJ: 2 | 5

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

3. Where will the nurse administer a medication that was ordered to be given sublingually?

a.

Between the molar teeth and cheek

b.

Below the skin surface

c.

Under the tongue

d.

Into the conjunctival sac

ANS: C

The sublingual area is underneath the tongue. Between the molar teeth and cheek is the buccal area. Medication administered below the skin surface is intradermal administration. The conjunctival sac is between the eyelids and eyeball.

DIF: Cognitive Level: Knowledge REF: p. 113 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Why are sublingual and buccal medications rapidly absorbed?

a.

Their action is localized to the mouth.

b.

They are metabolized in the liver.

c.

Blood flow is diminished in these sites.

d.

These drugs pass directly into systemic circulation.

ANS: D

Sublingual medications are rapidly absorbed into systemic circulation because of the increased blood flow to these areas and avoid the first pass effect of the liver where extensive metabolism usually takes place. These routes do not contain drug effects to the oral area and they bypass the liver. These sites are highly vascular.

DIF: Cognitive Level: Comprehension REF: p. 113 OBJ: 9

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

5. Which medications must be sterile?

a.

Topical

b.

Vaginal

c.

Ophthalmic

d.

Nasal

ANS: C

Ophthalmic (eye) medications must be sterile. Topical, vaginal, and nasal applications do not need to be sterile.

DIF: Cognitive Level: Knowledge REF: p. 113 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

6. Which action will the nurse perform when doing a wet to dry dressing every 4 hours on a patient with a deep wound?

a.

Pack the wound tightly with gauze.

b.

Saturate the dressing with as much liquid as possible.

c.

Use Montgomery tapes or a binder to secure the dressing.

d.

Apply the new moist dressing over the existing one.

ANS: C

The use of Montgomery tapes or a binder reduces the irritation of nearby skin tissue. The dressing should be packed into the wound loosely. The dressings should be wrung out to prevent dripping. The previous dressing should always be completely removed.

DIF: Cognitive Level: Application REF: p. 106 OBJ: 2

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

7. When applying nitroglycerin topically, which nursing intervention is correct?

a.

Secure the paper on two sides with tape.

b.

Shave the area prior to application of the paper.

c.

Wear gloves while placing the new paper.

d.

Remind the patient to discontinue use of the medication if chest pain is relieved.

ANS: C

Wearing gloves prevents accidental exposure to the medication. The area where the paper is placed should be covered with plastic wrap and taped into place to prevent medication from seeping out. Shaving may cause skin irritation. The dosage and frequency of application should be gradually reduced over 4 to 6 weeks, and the patient should contact the health care provider if adjustment is desired.

DIF: Cognitive Level: Application REF: p. 109 OBJ: 5

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

8. Where does the nurse correctly administer ophthalmic medication?

a.

At the inner canthus of the eye

b.

In the lower conjunctival sac

c.

Directly onto the eyeball

d.

To the outer corner of the eyelid

ANS: B

The lower conjunctival sac is exposed by applying gentle traction to the lower lid at the bony rim of the orbit. The inner canthus allows medication to flow out of the eye. Applying directly to the eyeball risks injury to the globe. The outer corner of the eyelid allows medication to flow out of the eye.

DIF: Cognitive Level: Knowledge REF: p. 113 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

9. Which effect would be important for the nurse to address when teaching a patient about the overuse of nose drops?

a.

Rebound

b.

Ceiling

c.

Idiosyncratic

d.

Measured

ANS: A

Rebound effect may occur with overuse of some medications. Ceiling effect is the greatest attainable response. An idiosyncratic effect may occur even with prudent use of nose drops. Measured effect is the patients response to the medication.

DIF: Cognitive Level: Application REF: p. 117 OBJ: 9 | 11

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

10. Which nursing assessment accurately describes the results of an intradermal skin test?

a.

Itching and weeping

b.

Erythema and induration

c.

Swelling and coolness

d.

Pallor and drainage

ANS: B

The result should be measured by diameter of erythema in millimeters, and the induration should be palpated and measured in millimeters. Itching is not relevant to the results; weeping should be reported to the health care provider but is not pertinent to the evaluation of the skin test. Swelling, coolness, pallor, and drainage are not relevant to evaluation; reporting this to the health care provider is appropriate, but not pertinent to the evaluation of the skin test.

DIF: Cognitive Level: Comprehension REF: p. 107 OBJ: 4

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity

11. The nurse is teaching a patient about nitroglycerin ointment. Which is an advantage of this form of the medication?

a.

It does not give the patient a bad taste in the mouth.

b.

The amount of ointment does not matter in obtaining a therapeutic response.

c.

It does not cause headaches as an adverse effect.

d.

It provides relief of anginal pain for several hours longer than sublingual medication.

ANS: D

Nitroglycerin ointment provides relief of anginal pain for several hours longer than sublingual preparations. Nitroglycerin pills do not have a bad taste. Dosage is critical to the success of use. All nitroglycerin preparations may cause headaches because of vasodilation.

DIF: Cognitive Level: Comprehension REF: p. 109 OBJ: 5

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

12. A patient with metastatic cancer is being admitted for pain control. Which action will the nurse perform in administering a transdermal patch?

a.

After removal, dispose of the old patch in a receptacle in the patients room.

b.

Change the fentanyl patch every day, either in the morning or at bedtime.

c.

Hold the short acting oral pain medication when a fentanyl patch is initiated.

d.

Label the patch with date, time, dosage, and initials after patch placement.

ANS: D

Labeling is appropriate when transdermal disks are placed. Patches are to be disposed of in a receptacle on the medication cart, not in the patients room. Fentanyl patches are changed every 72 hours. Fentanyl patches take up to 12 hours to be effective; therefore, short acting pain medication is continued.

DIF: Cognitive Level: Application REF: p. 111 OBJ: 7

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

13. What is the rationale for the nurse applying gentle pressure to the inner corner of the eyelid after instilling eye drops?

a.

Decreases the risk of infection

b.

Maintains intraocular pressure

c.

Prevents systemic effects

d.

Provides comfort to the patient

ANS: C

Application of pressure to the inner corner of the eye prevents the medication from entering the canal, where it would be absorbed in the vascular mucosa of the nose and produce systemic effects. Application of pressure to the inner corner of the eye does not decrease infection, maintain intraocular pressure, or promote patient comfort.

DIF: Cognitive Level: Application REF: p. 114 OBJ: 9

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is instructing a patient to use a corticosteroid inhaler. Which statement by the patient indicates the need for further teaching?

a.

I will shake the inhaler before I use it.

b.

I need to rinse my mouth after I use the inhaler.

c.

I will use this when Im lying in bed in the morning.

d.

After I inhale, I will hold my breath and then breathe out slowly.

ANS: C

The sitting position allows for maximum lung expansion. Shaking the inhaler helps to disperse the medication. The mouth needs to be rinsed after the inhalation of a corticosteroid. Holding the breath then exhaling slowly allows the drug to settle into pulmonary tissue.

DIF: Cognitive Level: Application REF: p. 119 OBJ: 11

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

15. What is the appropriate nursing action when administering a vaginal suppository?

a.

Ask the patient to urinate prior to insertion.

b.

Assist the patient to a side lying position.

c.

Keep suppository refrigerated prior to insertion.

d.

Insert the suppository 1 inch into the vagina.

ANS: A

An empty bladder facilitates insertion. Side lying position would not facilitate insertion of a vaginal suppository. Suppository needs to be warmed to room temperature before it is administered. The suppository is inserted more than 1 inch.

DIF: Cognitive Level: Application REF: p. 121 OBJ: 12

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

16. Which is an accurate nursing action when treating a patients rash with a lotion?

a.

Avoid shaking the container prior to application.

b.

Cleanse area with alcohol prior to treatment.

c.

Cover the area with gauze because of the oil base.

d.

Pat on the area with a gloved hand.

ANS: D

To prevent increased circulation and itching, lotions should be gently but firmly patted on the skin, rather than rubbed in. Shake all lotions thoroughly immediately before application. Lotions are aqueous and are easily cleansed with water. Lotions are not oil based.

DIF: Cognitive Level: Application REF: p. 105 OBJ: 2

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

17. A 2-year-old child is hospitalized with the diagnosis of tonsillitis and bilateral otitis media. The nurse is preparing to administer ear drops. When instilling the ear drops, the nurse will pull the earlobe:

a.

upward and back.

b.

sideways and down.

c.

downward and back.

d.

sideways and up.

ANS: C

For children under 3 years, pull the earlobe downward and back with ear drop instillation to straighten the external auditory canal. The earlobe is pulled up and back for adults and children ages 3 and over.

DIF: Cognitive Level: Comprehension REF: p. 116 OBJ: 10

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

18. The nurse is preparing an otic solution. When instructing the patient in regard to area of administration, the nurse will explain that the solution will be placed:

a.

into the eye.

b.

under the tongue.

c.

topically.

d.

into the ear.

ANS: D

Medications for use in the ear are labeled otic. Ophthalmic solutions are administered into the eye. Sublingual medications are administered under the tongue. Topical medications are applied to the skin.

DIF: Cognitive Level: Application REF: p. 115 OBJ: 10

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

19. Which order(s) would be examples of percutaneous medication administration? (Select all that apply.)

a.

Timolol 0.5% 1 drop to each eye daily

b.

Albuterol nebulizer 2.5 mg qid

c.

Heparin 5000 units IV

d.

Lasix 20 mg PO every AM

e.

Silvadene 1% topically to affected area

ANS: A, B, E

Percutaneous administration refers to applying medications to the skin or mucous membranes for absorption, such as eye drops.

DIF: Cognitive Level: Application REF: p. 105 OBJ: 1

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

20. Which action(s) will the nurse perform when preparing to administer a topical medication? (Select all that apply.)

a.

Wash hands before and after administration.

b.

Maintain a dry environment to encourage wound healing.

c.

Wear gloves during the application process.

d.

Use sterile dressings for all wounds.

ANS: A, C

Handwashing is an essential part of medication administration. Gloves are worn with topical medication to prevent absorption into the practitioners own skin. Dryness does not encourage wound healing. Sterile dressings do not work well for all wounds.

DIF: Cognitive Level: Application REF: p. 106 OBJ: 1 | 2

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

21. Which dressings would be appropriate to use for treating wounds with exudates?

a.

AlgiDERM

b.

Telfa

c.

Kaltostat

d.

Sorbsan

e.

OpSite

ANS: A, C, D

AlgiDERM, Kaltostat, and Sorbsan are exudate absorbers for use in treating infected wounds. Telfa and OpSite are not appropriate to use on wounds with exudates.

DIF: Cognitive Level: Knowledge REF: p. 105 OBJ: 1

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

OTHER

22. Place the following steps for administration of nose drops in the correct order. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.)

A. Draw medication into the dropper.

B. Instruct patient to blow the nose gently.

C. Review practice setting policy.

D. Explain the steps to the patient.

E. Position the patient into supine position with head backward over edge of bed.

F. Instill medication.

ANS:

C, D, B, E, A, F

DIF: Cognitive Level: Analysis REF: pp. 116-117 OBJ: 11

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

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