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fundamentals exam 4 latest
The clinical nurse educator at a long-term care facility is responsible for organizing and carrying out staff education sessions. Which of the following topics for staff education is most likely to benefit the greatest number of residents? A) Educating nurses on how to prevent falls B) Reviewing safe medication administration C) Educating nurses on how to prevent wandering by confused residents D)
Reviewing resuscitation for cardiac and respiratory arrest - verified answer Ans:
A
Feedback: Falls remain the leading cause of death among older adult Americans. Education that aims to reduce the incidence of falls is likely to be of more benefit than measures that address medication administration, prevention of wandering, or resuscitation procedures, even though such topics may be of importance. A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?
A)
Place it in the client's medical record. B) Take it home and keep it locked up. C) Maintain it according to agency policy. D)
Include it with documentation of the error. - verified answer Ans:
C
Feedback: An accident in a health care agency requires filling out an incident report, a confidential document that objectively describes the circumstances of the accident. The incident report is not a part of the medical record and should not be mentioned in the documentation. The report is maintained by the agency. A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which of the following is a prudent nursing intervention for this client? A) Briefly leave the client in order to call the primary physician to assess the client's condition.
Report the incident to the supervising nurse. C) Check the client's condition. D)
Fill in the accident report sheet. - verified answer Ans:
C
Feedback: On detection of the medication error, the nurse should immediately check the client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintain the client's safety. As soon as the nurse recognizes an error, he or she should check the client's condition and report the mistake to the prescriber and supervising nurse immediately. Health care agencies have a form for reporting medication errors called an incident sheet or accident sheet. The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? A) The nurse positions a patient in a supine position prior to applying wrist restraints. B) The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. C) The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist.
D) The nurse ties an elbow restraint to the raised side rail of a patient's bed. - verified answer b.
The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.
The medical chart of a newly admitted client notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's wound culture and sensitivity. How should the nurse respond to this situation? A) Withhold the medication until the potential drug allergy has been addressed by the care team. B) Administer the medication and increase the frequency of assessments in the hours that follow. C) Substitute an antibiotic with similar action, but which is from a different drug family. D) Discuss the severity, signs and symptoms of the drug allergy with the client in order to ascertain the
risks of administration. - verified answer Ans:
A
Feedback: Client safety is paramount, and the nurse has a responsibility to ensure that a potential threat of harm is identified and dealt with promptly. It is beyond the nurse's scope of practice to independently substitute another drug, and it would be unsafe to administer the drug in light of this revelation. The nurse would not administer the drug even if the client stated that his or her allergy is mild. A physician has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen?
Immediately after the order is noted C) Not until verifying it with the client D)
Whenever the client asks for it - verified answer Ans:
B
Feedback: A stat order is a single order, and it is carried out immediately. This is a legal order. The nurse would not wait until the next scheduled medication time or verify the order with the client. With a p.r.n. order, the client receives medication when it is requested or required. What does the nurse do to verify an order for a medication listed on a medication administration record (MAR)? A) Compare it with the original physician's order. B) Ask another nurse what the drug is. C)
Look up the drug in a textbook. D)
Call the pharmacist for verification. - verified answer Ans:
A
Feedback: In many institutions, the medication order is copied onto the client's medication record. The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original physician's order. A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets? A) To prevent absorption in the mouth B) To prevent absorption in the esophagus C) To facilitate absorption in the stomach D) To prevent gastric irritation
Feedback: Teach clients the names of drugs rather than distinguishing drugs by color. Manufacturers may vary the color of generic drugs, and the visual changes associated with aging may make it more difficult to identify medications by color. Medications should not be identified by counting or by shapes. What would a nurse instruct a client to do after administration of a sublingual medication? A) "Take a big drink of water and swallow the pill." B) "Try not to swallow while the pill dissolves." C) "Swallow frequently to get the best benefit." D)
"Chew the pill so it will dissolve faster." - verified answer Ans:
B
Feedback: Sublingual and buccal medications should not be swallowed, but rather held in place so that complete absorption takes place.
A nurse is administering an intramuscular injection of a viscous medication using the appropriate- gauge needle. What does the nurse need to know about needle gauges? A) All needles for parenteral injection are the same gauge. B) The gauge will depend on the length of the needle. C) Ask the client what size needle is preferred. D)
Gauges range from 18 to 30, with 18 being the largest. - verified answer Ans:
D
Feedback: The gauge is determined by the diameter of the needle and ranges from 18 to 30. As the diameter of the needle increases, the gauge number decreases (an 18-gauge needle is, therefore, larger than a 30-gauge needle). A viscous medication requires a larger-gauge needle for injection A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? A)
C)
Insulin syringe, 1-inch 16-gauge needle D)
Tuberculin syringe, 1/2-inch 26-gauge needle - verified answer Ans:
D
Feedback: Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter. A quarter-inch to half-inch 26- or 27-gauge needle is used. A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order? A) Ask the physician to repeat the dosage. B) Ask the physician to spell out the medication name. C) Ask a second nurse to listen for accuracy. D)
Ask the physician to write out the order. - verified answer Ans:
D
Feedback: To maintain the accuracy of a verbal order, the nurse should tactfully ask the physician for a written order. When obtaining phone orders, it is important to repeat the dosages of medications and to spell medication names for confirmation of accuracy. Some nurses may ask a second nurse to listen to a telephone order on an extension. A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration? A) Ensures that the right medication is given at the right time by the right route B) Complies with the medical order and ensures that the right dose is given C) Ensures that the medication has been administered to the right client D)
Demonstrates timely administration and compliance with the medical order - verified answer Ans:
A
Feedback: Intradermal injection routes are commonly used for tuberculin tests and allergy testing because they are administered between the layers of the skin. A subcutaneous injection is not suitable because it is administered more deeply than an intradermal injection; whereas, an intramuscular injection is administered in one muscle or muscle group. Intravenous injection is also not suitable because it is instilled into veins. A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which of the following is the most suitable angle when administering an intradermal injection? A) 180-degree angle B) 90-degree angle C) 45-degree angle D)
10-degree angle - verified answer Ans:
D
Feedback: When administering an intradermal injection, the nurse should hold the syringe almost parallel to the skin at a 10-degree angle with the bevel pointing upward. This facilitates delivering the
medication between the layers of the skin and advances the needle to the desired depth. A nurse administers a subcutaneous injection at a 45-degree angle or a 90-degree angle to reach the subcutaneous level of tissue, depending on the length of the needle. The nurse will not be able to insert the injection if it is held at a 180-degree angle. A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which of the following precautions should the nurse take when storing narcotic medications? A) In a double-locked drawer B) In a single container C) In a self-contained packet D)
In disguised containers - verified answer Ans:
A
Feedback: The nurse should place narcotic drugs in a double-locked drawer. Narcotics are controlled substances, meaning that federal laws regulate their possession and administration. Health care facilities keep narcotics in a double-locked drawer, box, or room on the nursing unit. A narcotic drug may not be placed in a single container, self-contained packet, or in disguised containers.
A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment? A) Shaking the contents of the ointment B) Applying inunction with a cotton ball C) Rubbing the ointment into the skin D)
Warming the inunction before application - verified answer Ans:
C
Feedback: In order to promote absorption, the nurse should rub the ointment into the client's skin. Shaking the contents would mix the contents uniformly, whereas applying the with a cotton ball would distribute the substance over a wide area. Warming the ointment before application would provide comfort. A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client? A)
Manipulation of the client's ear to straighten the auditory canal B) Dilution of the medication drops before instilling in the client's ear C) Position in which the client remains until medication reaches the eardrum D)
Amount of time before instilling medication in the client's opposite ear - verified answer Ans:
A
Feedback: The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription, and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum, and the amount of time before instilling medication in the client's opposite ear, does not differ with the age of the client A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which of the following points should the nurse tell the client in order to avoid lipoatrophy and lipohypertrophy? A) Change the needle daily with each injection.
