Nursing Chapter 35 Process Implementation Learning Outcome 16 Verbalize The

Kozier & Erb’s 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.

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.

Question 3

Type: MCSA

The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101°F. 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 101°F.

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.

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.

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.

Question 6

Type: MCSA

The nurse is preparing to administer a medication to a 6-year-old client. What is the nurse’s 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.

Question 7

Type: MCSA

During the process of administering medications, the nurse checks the name band for the client’s name. What

should be this nurse’s next action?

1. Administer the medication as ordered.

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

3. Double check the client’s identification using a second method.

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

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.

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 client’s 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.

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.

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.

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.

Question 13

Type: MCSA

During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible

under the client’s 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.

Question 14

Type: MCSA

The nurse has just injected insulin subcutaneously into the client’s abdomen. What action should the nurse take at

this point?

1. Massage the site to encourage absorption.

2. Leave the needle embedded in the client’s 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.

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

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.

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.

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.

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.

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.

Question 21

Type: MCSA

While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the

client’s 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 client’s skin.

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

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.

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.”

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.