Medicaiton Administration/IV (ch. 31)

Question 1

When preparing to administer a new medication, what would the nurse do first to ensure the patient’s safety?

Answer 1

Compare the written order with the medication administration record (MAR).

Question 2

How might the nurse safely administer an extended-release capsule to a patient with dysphagia?

Answer 2

Place capsule in a spoonful of food (ex. applesauce)

Question 3

As the nurse is at the bedside preparing to administer a new medication, the patient mentions that he is allergic to the drug. What will the nurse do first?

Answer 3

Withhold the drug

Question 4

As the nurse is giving a patient his medications, he remarks, “I’ve never seen this blue pill before.” What is the nurse’s correct response?

Answer 4

“Don’t take it. Let me double-check the doctor’s order to make sure this is the correct medication for you.”

Question 5

Which of the following is not taken into consideration when determining the appropriate amount of a topical medication to be applied to the skin?

Answer 5

Other medications being taken

Question 6

Which statement best illustrates the nurse’s understanding of appropriate sites for the application of an estrogen patch?

Answer 6

“I need to assess the skin on the patient’s thighs.”

Question 7

When instructing a patient in the use of a dry powder inhaler (DPI), which statement is accurate?

Answer 7

It is important to read the manufacturer’s instructions to determine how quickly to inhale the medication.

Question 8

A female nurse is preparing to administer a rectal suppository to a male patient. The patient says, “This is so embarrassing. Is this really necessary?” What is the most appropriate response?

Answer 8

“How about if I show you how to insert the suppository yourself?”

Question 9

After administering a rectal suppository for constipation, the nurse will monitor for all of the following responses except which one?

Answer 9

Low platelet count (done before)

Question 10

When preparing an injection from an ampule, what will the nurse do if liquid is trapped in the neck of the ampule?

Answer 10

Check the medication cabinet for an extra ampule of the medication.

Question 11

When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection?

Answer 11

Insert air into the intermediate-acting insulin.

Question 12

When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe?

Answer 12

By noting when 5 units of clear insulin is visible in the syringe

Question 13

Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe?

Answer 13

Prepare two injections.

Question 14

When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again?

Answer 14

Inability to feel resistance when injecting the medication

Question 15

Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test?

Answer 15

A hard, raised area 15 mm or greater in diameter

Question 16

Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size?

Answer 16

Make sure the volume of the medication is less than 2 mL.

Question 17

What can the nurse do to minimize the discomfort of a subcutaneous injection?

Answer 17

Cover the injection site with gauze pad after withdrawing the needle.

Question 18

Which action by the nurse ensures patient safety when administering an intramuscular injection?

Answer 18

Rotating injection sites

Question 19

What can the nurse do to minimize the patient’s risk for injury when delivering an intramuscular injection?

Answer 19

Pull back on the plunger after inserting the needle.

Question 20

Which site is most commonly used for intramuscular injections?

Answer 20

Ventrogluteal

Question 21

When preparing to insert a venous access device, how can the nurse encourage patient compliance with the procedure?

Answer 21

Assess the patient’s understanding of the placement of the device.

Question 22

The nurse is inserting an over-the-needle catheter into a newly admitted patient. What will the nurse do after confirming blood return?

Answer 22

Lower the catheter until it is flush with the skin.

Question 23

When applying a dressing to an infusion site on a patient’s left forearm, what will the nurse do to ensure proper maintenance of the tubing?

Answer 23

Apply the dressing proximal to the tubing and catheter hub connector.

Question 24

Which action will the nurse take to minimize a patient’s risk for injury when applying a gauze dressing to an infusion site?

Answer 24

Avoid encircling the arm with tape

Question 25

What might the nurse do to minimize the risk for injury in a patient receiving IV therapy?

Answer 25

Regulate the flow rate of the infusion.

Question 26

The nurse observes erythema at the insertion site of a patient’s IV infusion device. When asked, the patient denies pain at the site. Using the phlebitis scale, what score does the nurse give the injury?

Answer 26

1

Question 27

A patient’s IV site has developed phlebitis scored as a 4 on the phlebitis scale. What would the nurse do to help treat the site?

Answer 27

Apply a warm compress

Question 28

What would the nurse do to assess a patient’s risk for embolus when removing a venous access device?

Answer 28

Visualize the tip of the IV device.

Question 29

Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock?

Answer 29

Flush the saline lock with sodium chloride solution before initiating the infusion.

Question 30

If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step?

Answer 30

Assess the site for swelling or coolness while flushing the saline lock with normal saline.
(Blood return may be absent with a smaller-gauge catheter. Infusing normal saline while checking for infiltration ensures that the catheter tip is both patent and in the vein)