week 5 book ch 31

Question 1

It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication?

1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart.
2. Before going to patient’s room, comparing patient’s name and name of medication on label of prepared drugs with MAR.
3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout.
4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient’s bedside.

Answer 1

2. Before going to patient’s room, comparing patient’s name and name of medication on label of prepared drugs with MAR.

Question 2

An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.)

1. Provide a dispensing system for each day of the week.
2. Provide larger, easier-to-read labels.
3. Tell the patient what is in each container.
4. Have a family caregiver administer the medication.
5. Use teach-back to ensure that the patient knows what medication to take and when.

Answer 2

1. Provide a dispensing system for each day of the week.
2. Provide larger, easier-to-read labels.
3. Use teach-back to ensure that the patient knows what medication to take and when.

Question 3

The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply).

1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized.
2. Clearly identify patient’s name, room number, and diagnosis.
3. Read back all orders to health care provider.
4. Use clarification questions to avoid misunderstandings.
5. Write “VO” (verbal order) or “TO” (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Answer 3

1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized.
2. Clearly identify patient’s name, room number, and diagnosis.
3. Read back all orders to health care provider.
4. Use clarification questions to avoid misunderstandings.
5. Write “VO” (verbal order) or “TO” (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Question 4

A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment.

1. Clean eye, washing from inner to outer canthus.
2. Assess patient’s level of consciousness and ability to follow instructions.
3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva.
4. Have patient close eye and rub lightly in a circular motion with a cotton ball.
5. Ask patient to look at ceiling, and explain the steps to patient.

Answer 4

2. Assess patient’s level of consciousness and ability to follow instructions.
3. Clean eye, washing from inner to outer canthus.
4. Ask patient to look at ceiling, and explain the steps to patient.
5. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva.
6. Have patient close eye and rub lightly in a circular motion with a cotton ball.

Question 5

A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order.

1. Insert MDI into end of spacer.
2. Perform a respiratory assessment.
3. Remove mouthpiece from MDI and spacer device.
4. Place the spacer mouthpiece into patient’s mouth, and instruct patient to close lips around the mouthpiece.
5. Depress medication canister, spraying 1 puff into spacer device.
6. Shake inhaler for 2-5 seconds.
7. Instruct patient to hold breath for 10 seconds.
8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.

Answer 5

2. Perform a respiratory assessment.
3. Remove mouthpiece from MDI and spacer device.
4. Shake inhaler for 2-5 seconds.
5. Insert MDI into end of spacer.
6. Place the spacer mouthpiece into patient’s mouth, and instruct patient to close lips around the mouthpiece.
7. Depress medication canister, spraying 1 puff into spacer device.
8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.
9. Instruct patient to hold breath for 10 seconds.

Question 6

A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.)

1. Verifying tube placement after medications are given
2. Mixing all medications together to give all at once
3. Using an enteral tube syringe to administer medications
4. Flushing tube with 30 to 60 mL of water after the last dose of medication
5. Checking for gastric residual before giving the medications
6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given

Answer 6

3. Using an enteral tube syringe to administer medications
4. Flushing tube with 30 to 60 mL of water after the last dose of medication
5. Checking for gastric residual before giving the medications
6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given

Question 7

Place the steps of administering an intradermal injection in the correct order.

1. Inject medication slowly.
2. Note the presence of a bleb.
3. Advance needle through epidermis to 3 mm.
4. Using nondominant hand, stretch skin over site with forefinger.
5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt.
6. Cleanse site with antiseptic swab.

Answer 7

6. Cleanse site with antiseptic swab.
7. Using nondominant hand, stretch skin over site with forefinger.
8. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt.
9. Advance needle through epidermis to 3 mm.
10. Inject medication slowly.
11. Note the presence of a bleb.

Question 8

After receiving an intramuscular (IM) injection in the deltoid, a patient states, “My arm really hurts. It’s burning and tingling where I got my injection.” What should the nurse do next? (Select all that apply.)

1. Assess the injection site.
2. Administer an oral medication for pain.
3. Notify the patient’s health care provider of assessment findings.
4. Document assessment findings and related interventions in the patient’s medical record.
5. This is a normal finding, so nothing needs to be done.
6. Apply ice to the site for relief of burning pain.

Answer 8

1. Assess the injection site.
2. Notify the patient’s health care provider of assessment findings.
3. Document assessment findings and related interventions in the patient’s medical record.

Question 9

idiosyncratic reaction

Answer 9

a patient overreacts/under-reacts to a medication different from normal

Question 10

most tablets need ____ of fluid

Answer 10

60-240 ml

Question 11

oral routes include

Answer 11

sublingual
buccal

Question 12

parenteral routes

Answer 12

*injection
intradermal
subcutaneous
intramuscular
intravenous

Question 13

Z-track method

Answer 13

pulls skin during an injection
**IM injections

Question 14

Medications must have

Answer 14

1. client name
2. date/time
3. medication name
4. dosage
5. route
6. time/frequency
7. provider signature

Question 15

preferred and safest site for injection in children & adults

Answer 15

ventrogluteal
Leg w/ “v-shape”