Medication & Vital Signs Exam: Questions with Solutions for Nursing Students, Exams of Medicine

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Medication & Vital Signs Exam

Questions with Solutions

Know your medications (Before administering any medication) - ANS: Before administering any medication, know the following:

1. Mode of action and purpose of medication (making sure that this medication is appropriate for the patient's diagnosis)
2. Adverse effects of and contraindications for the medication
3. Antagonist of medication (as appropriate)
4. Safe dosage range for medication
5. Potential interactions with other medications
6. Precautions to take before administration
7. Proper administration technique KNOW YOUR MEDICATION - ANS: 1. Action
8. Special nursing consideration
9. Safe dose ranges
10. purpose of administration
11. Adverse effects
12. patient's allergy (Double check with Patient) YOU ARE RESPONSIBLE FOR - ANS: 1. patient's care
13. Appropriateness of medication
14. Utilizing administration guide
15. Three checks
16. rights of medication administration The Three Checks-

the label on the medication package or container should be checked three times during medication preparation and administration. - ANS: 1. Read the Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR) and select the proper medication from the patient's medication drawer or medication supply system. This is the first check of the medication label.

2. After retrieving the medication from the drawer, compare the medication label with the eMAR/MAR. Note: Compare with the eMAR/MAR immediately before pouring from a multidose container. This is the second check of the medication label.
3. The third check can be performed in one of two ways, depending on facility policy: Most commonly, at the bedside, recheck the labels with the eMAR/MAR after identifying the patient and before administrati on.When all medications for one patient have been prepared, recheck the labels with the eMAR/MAR before taking the medication to the patient. Rights of Medication Administration - ANS: 1. Right medication is given to the
4. Right patient in the
5. Right dosage (in the right form) through the
6. Right route at the
7. Right time for the
8. Right reason based on the
9. Right (appropriate) assessment data using the
10. Right documentation and monitoring for the
11. Right response by the patient. NURSING RESPONSIBILITIES FOR ADMINISTERING DRUGS - ANS: 1. Assessing the patient and understanding clearly why the patient is receiving a particular medication
12. Preparing the medication to be administered using accurate dosage calculations
13. Validating medication calculations with another nurse
14. Administering medication and documenting it has been given
15. Monitoring patient reaction and response
16. Educating patients regarding their medication regimen

6. Verify the patient's name as well as the dose, route, and time of administration. Unit dose packaging - ANS: Unit dose packages: Do not open the wrapper until at the bedside. Keep opioids and medications that require special nursing assessments separate from other medication packages. *Wrapper is kept intact because the label is needed for an additional safety check. Special assessments may be required before giving certain medications. These may include assessing vital signs and checking laboratory test results. Multidose containers - ANS: Multidose containers: When removing tablets or capsules from a multidose bottle, pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Break only scored tablets, if necessary, to obtain the proper dosage. Do not touch tablets or capsules with hands. *Pouring medication into the cap allows for easy return of excess medication to the bottle. Pouring tablets or capsules into your hand is unsanitary. Liquid medication in multidose bottle - ANS: Liquid medication in multidose bottle: When pouring liquid medications out of a multidose bottle, hold the bottle so the label is against the palm. Use the appropriate measuring device when pouring liquids, and read the amount of medication at the bottom of the meniscus at eye level (Figure 2). Wipe the lip of the bottle with a paper towel Liquid that may drip onto the label makes the label difficult to read. Accuracy is possible when the appropriate measuring device is used and then read accurately. Patient states that it feels like medication is lodged in throat: - ANS: Offer patient more fluids to drink. If allowed, offer the patient bread or crackers to help move the medication to the stomach. It is unclear whether the patient swallowed the medication: - ANS: Check in the patient's mouth, under tongue, and between cheek and gum. Patients with altered cognition may not be aware that the medication was not swallowed. Also, patients may "cheek" medications to avoid taking the medication or to save it for later use.

Patient vomits immediately or shortly after receiving oral medication: - ANS: Assess vomit, looking for pills or fragments. Do not re-administer medication without notifying the primary health care provider. If a whole pill is seen and can be identified, the primary health care provider may ask that the medication be administered again. If a pill is not seen or medications cannot be identified, do not re- administer the medication in order to prevent the patient from receiving too large a dose. Child refuses to take oral medications: - ANS: Some medications may be mixed in a small amount of food, such as pudding or ice cream. Do not add the medication to liquids because the medication may alter the taste of liquids; if child then refuses to drink the rest of the liquid, you will not know how much of the medication was ingested. Use creativity when devising ways to administer medications to a child. See the section below, Infant and Child Considerations, for suggestions. Capsule or tablet falls to the floor during administration: - ANS: Discard and obtain a new dose for administration. This prevents contamination and transmission of microorganisms. Patient refuses medication: - ANS: Explore the reason for the patient's refusal. Review the rationale for use of the drug, explain the risk of refusal, and any other information that may be appropriate. If you are unable to administer the medication despite education and discussion, document the omission and any education and/or explanation provided related to attempts to facilitate administration according to facility policy. The primary care provider should be informed of the refusal when the omission poses a specific threat to the patient The peripheral pulse - ANS: The peripheral pulse is a throbbing sensation that can be palpated (felt) over a peripheral artery, such as the radial artery or the carotid artery. Peripheral pulses result from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle. Each time the left ventricle contracts to eject blood into an already full aorta, the arterial walls in the cardiovascular system expand to compensate for the increase in pressure of the blood. The peripheral pulses may be felt wherever an artery passes over a solid structure, such as bone or cartilage. Characteristics of the peripheral pulse include rate, rhythm, and amplitude (quality; strong or weak). These characteristics are indicators of the effectiveness of the heart as a pump, the volume of blood ejected with each heartbeat (stroke volume), and the adequacy of peripheral blood flow. Pulse Rate - ANS: Pulse rates are measured in beats per minute. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats per minute. Pulse amplitude (quality) describes the quality of the pulse in terms of its fullness—strong or weak. It is assessed by the feel of the blood flow through the vessel. Pulse rhythm is the pattern of the pulsations and the pauses between them. Pulse rhythm is normally regular; the pulsations and the pauses between occur at regular intervals. An irregular pulse rhythm occurs when the pulsations and pauses between beats occur at unequal intervals.

the patient's age, amount of exercise, fluid balance, and medications. Note baseline or previous pulse measurements. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient's current status. Appropriate nursing diagnoses may include: - ANS: Decreased cardiac output Ineffective peripheral tissue perfusion Risk for ineffective peripheral tissue perfusion Method of Pulse taking - ANS: 8. Place your first, second, and third fingers over the artery (Figure 1). Place your fingers over the artery so that the ends of your fingers are flat against the patient's skin when palpating peripheral pulses. Do not press with the tip of the fingers only. Lightly compress the artery so pulsations can be felt and counted. The sensitive fingertips can feel the pulsation of the artery.

9. Using a watch with a second hand, count the number of pulsations felt for 30 seconds (Figure 2). Multiply this number by 2 to calculate the rate for 1 minute. If the rate, rhythm, or amplitude of the pulse is abnormal in any way, palpate and count the pulse for 1 minute.
10. Note the rhythm and amplitude of the pulse. Pulse Rate: DOCUMENTATION - ANS: Guidelines Record pulse rate, amplitude, and rhythm in the electronic record or flow sheet. Identify site of assessment. Report abnormal findings to the primary care provider. Ex. 2/6/120 1000 Pulses 84, regular, 2+ and equal bilaterally in radial, popliteal, and dorsalis pedis sites. Unexpected Situations-Pulse
11. Irregular pulse

2. Pulse is easily palpated but then disappears
3. Can't palpate a pulse - ANS: The pulse is irregular: Monitor the pulse for a full minute. If the pulse is difficult to assess, validate pulse measurement by taking the apical pulse for 1 minute. If this is a change for the patient, notify the primary care provider. The pulse is palpated easily, but then disappears: Apply only moderate pressure to the pulse. Applying too much pressure may obliterate the pulse. You cannot palpate a pulse: Use a portable Doppler ultrasound to assess the pulse. If this is a change in assessment or if you cannot find the pulse using a Doppler ultrasound, notify the primary care provider. If you can find the pulse using a Doppler ultrasound, place a small X over the spot where the pulse is located. This can make palpating the pulse easier because the exact location of the pulse is known. General Considerations-Pulse Rate - ANS: 1. The normal heart rate varies by age.
4. The carotid pulse should be palpated only in the lower third of the neck to avoid stimulation of the carotid sinus. When palpating a carotid pulse, lightly press only one side of the neck at a time. Never attempt to palpate both carotid arteries at the same time. Bilateral palpation could result in reduced cerebral blood flow and cause the patient to lose consciousness (Jensen, 2015).
5. If a peripheral pulse is difficult to assess accurately because it is irregular, feeble, or extremely rapid, assess the apical rate. Infant and Child Considerations
6. Infants and toddlers
7. Children older than 2 years VS Children younger than 2 years
8. Child with the cardiac problem or congenital heart defects - ANS: 1. In infants and toddlers, palpate or auscultate an apical rate
9. In children older than 2 years, use the radial site for pulse assessment and count for 1 minute. Do not measure the radial pulse in children younger than 2 years of age, because it is difficult to palpate accurately in this age group. In older children, measure the radial pulse for a full minute.
10. Measure the apical rate if the child has a cardiac problem or congenital heart defect (see Skill 2-5).

Method of Apical Pulse - ANS: 6. Use an alcohol swab to clean the diaphragm of the stethoscope. Use another swab to clean the earpieces, if necessary. Cleaning with alcohol deters transmission of microorganisms.

7. Assist the patient to a sitting or reclining position and expose the chest area. This position facilitates identification of the site for stethoscope placement.
8. Move the patient's clothing to expose only the apical site.-The site must be exposed for pulse assessment. Exposing only the apical site keeps the patient warm and maintains his or her dignity.
9. Hold the stethoscope diaphragm against the palm of your hand for a few seconds.
10. Palpate the space between the fifth and sixth ribs (fifth intercostal space), and move to the left midclavicular line. Place the stethoscope diaphragm over the apex of the heart (Figures 1 and 2). -Position the stethoscope over the apex of the heart, where the heartbeat is best heard. . Listen for heart sounds ("lub-dub"). Each "lub-dub" counts as one beat.-These sounds occur as the heart valves close.
11. Using a watch with a second hand, count the heartbeat for 1 minute.-Counting for a full minute increases the accuracy of assessment
12. Note the rhythm of the beats.-Provides additional assessment data regarding the patient's cardiovascular status.
13. When measurement is completed, cover the patient and help him or her to a position of comfort. Ensures patient comfort.
14. Clean the diaphragm of the stethoscope with an alcohol swab.

Cleaning with alcohol deters transmission of microorganisms. Special consideration-Infants and child considerations - ANS: Assess the apical pulse just above and outside the left nipple of the infant at the third or fourth intercostal space. As the child ages, the location for assessment moves to a more medial and slightly lower area until 7 years of age. In children age 7 years or older, assess the apical pulse at the fourth or fifth intercostal space at the midclavicular line (Jensen, 2015). The apical pulse is most reliable for infants and small children. Count the rate for 1 full minute in infants and children because of possible rhythm irregularities (Perry et al., 2014). Allow the young child to examine or handle the stethoscope to become familiar with the equipment. Apical rate of infants is easily palpated with the fingertips. Apical-Pulse deficients - ANS: Measurement of the apical-radial pulse deficit may be utilized to assess the effectiveness of the contractions of the heart, specifically the left ventricle. Counting of the pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical-radial pulse deficit. A difference between the apical and radial pulse rates is called the pulse deficit and indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated (Taylor et al., 2019). Two nurses are required to perform this skill; one listens with a stethoscope over the apex of the heart for the apical heart rate and the other counts the pulse rate at the radial artery. FULL 1 MINUTES Respiration - ANS: Under normal conditions, healthy adults breathe about 12 to 20 times per minute (respirations per minute). Infants and children breathe more rapidly. The depth of respirations varies normally from shallow to deep. The rhythm of respirations is normally regular, with each inhalation/exhalation and the pauses between occurring at regular intervals. An irregular respiratory rhythm occurs when the inhalation/exhalation cycle and the pauses between occur at unequal intervals. Assess respiratory rate, depth, and rhythm by inspection (observing and listening) or by listening with the stethoscope. Determine the rate by counting the number of breaths per minute. If respirations are

Meningitis, severe brain damage Assessment of Respiration - ANS: Assess the patient for factors that could affect respirations, such as exercise, medications, smoking, chronic illness or conditions, neurologic injury, pain, and anxiety. Note baseline or previous respiratory measurements. Assess patient for any signs of respiratory distress, which include retractions, nasal flaring, grunting, orthopnea, or tachypnea. NURSING DIAGNOSIS-Respiration - ANS: Ineffective breathing pattern Impaired gas exchange Ineffective airway clearance Implementation-Respiration - ANS: 1. While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient's respirations-The patient may alter the rate of respirations if he or she is aware they are being counted.

2. Note the rise and fall of the patient's chest.-A complete cycle of an inspiration and an expiration composes one respiration.
3. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute.-Sufficient time is necessary to observe the rate, depth, and other characteristics.
4. If respirations are abnormal in any way, count the respirations for at least 1 full minute.-Increased time allows the detection of unequal timing between respirations.
5. Note the depth and rhythm of the respirations. Provides additional assessment data regarding the patient's respiratory status. 10/23/20 0830 Patient breathing at a rate of 16 respirations per minute. Respirations regular and unlabored.

Unexpected Situations - ANS: The patient is breathing with such shallow respirations that you cannot count the rate: Sometimes it is easier to count respirations by auscultating the lung sounds. Auscultate lung sounds and count respirations for 30 seconds. Multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, count for a full minute. Notify the primary health care provider of the respiratory rate and the shallowness and irregularity of the respirations. Special considerations-Respiration - ANS: If respiratory rate is irregular, count respirations for 1 minute. Infant and Child Considerations For infants, count respirations for 1 full minute due to a normally irregular rhythm. Assess respirations in infants and children when the child is resting or sitting quietly, because respiratory rate often changes when infants or young children cry, feed, or become more active. The most accurate respiratory rate is obtained when the infant or child is at rest (Jensen, 2015). Infants' respirations are primarily diaphragmatic; count abdominal movements to measure respiratory rate (Jensen, 2015). After 1 year of age, count thoracic movements (Kyle & Carman, 2017). Blood pressure - ANS: Blood pressure refers to the force of the blood against arterial walls. A. Systolic pressure is the highest point of pressure on arterial walls when the ventricles contract and push blood through the arteries at the beginning of systole. B. Diastole pressure: When the heart rests between beats during diastole, the pressure drops. The lowest pressure present on arterial walls during diastole is the diastolic pressure (Taylor et al., 2019). C. Pulse Pressure: The difference between the Systolic P. and Diastolic P. For example, if the blood pressure is 120/80 mm Hg, 120 is the systolic pressure and 80 is the diastolic pressure. The pulse pressure, in this case, is 40. Blood pressure, measured in millimeters of mercury (mm Hg), is recorded as a fraction. The numerator is the systolic pressure; the denominator is the diastolic pressure. To get an accurate assessment of blood pressure, you must know what equipment to use, which site to choose, and how to identify the sounds you hear.

throughout the procedure. If the patient is attached to a cardiac monitor, assess for arrhythmias. Immediately return the patient to a supine position if symptoms appear during the procedure. Do not have the patient stand if symptoms of hypotension occur when the patient is sitting. Use the following guidelines to assess for orthostatic hypotension:

1. Lower the head of the bed. Place the bed in a low position. Ask the patient to lie in a supine position for 3 to 10 minutes. At the end of this time, take initial blood pressure and pulse measurements.
2. Assist the patient to a sitting position on the side of the bed with the legs dangling. After 1 to 3 minutes, take the blood pressure and pulse measurements.
3. Assist the patient to stand, unless standing is contraindicated. Wait 2 to 3 minutes, then take blood pressure and pulse measurements. Record the measurements for each position, noting the position with the readings. A decrease in systolic blood pressure of ≥20 mm Hg or a decrease in diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position is significant for orthostatic hypotension Assessment of blood pressure - ANS: 1. Assess the brachial pulse, or the pulse appropriate for the site being used.
4. Assess for an intravenous infusion or breast or axilla surgery on the side of the body corresponding to the arm used.
5. Assess for the presence of a cast, arteriovenous shunt, or injured or diseased limb. If any of these conditions are present, do not use the affected arm to monitor blood pressure.
6. Assess the size of the limb so that the appropriate-sized blood pressure cuff can be used. The correct cuff should have a bladder length that is 80% of the arm circumference and a width that is at least 40% of the arm circumference: a length to width ratio of 2:1.
7. Assess for factors that could affect blood pressure reading, such as the patient's age, exercise, position, weight, fluid balance, smoking, and medications. Note baseline or previous blood pressure measurements.
8. Assess the patient for pain. If the patient reports pain, give pain medication as ordered before assessing blood pressure. If the blood pressure is taken while the patient is in pain, make a notation concerning the pain if the blood pressure is elevated. NURSING DIAGNOSIS: Blood Pressure - ANS: Decreased cardiac output

Risk for falls Risk for unstable blood pressure Arm Position-BP - ANS: Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and the palm of the hand upward (Figure 1). If the measurement is taken in the supine position, support the arm with a pillow. In the sitting position, support the arm yourself or by using the bedside table. If the patient is sitting, have the patient sit back in the chair so that the chair supports his or her back. In addition, make sure the patient keeps the legs uncrossed. The position of the arm can have a major influence when the blood pressure is measured; if the upper arm is below the level of the right atrium, the readings will be too high. If the arm is above the level of the heart, the readings will be too low (Pickering et al., 2005). If the back is not supported, the diastolic pressure may be elevated falsely; if the legs are crossed, the systolic pressure may be elevated falsely (Pickering et al., 2005). This position places the brachial artery on the inner aspect of the elbow so that the bell or diaphragm of the stethoscope can rest on it easily. This sitting position ensures accuracy. Expose the brachial artery by removing garments or move a sleeve if it is not too tight, above the area where the cuff will be placed. Clothing over the artery interferes with the ability to hear sounds and can cause inaccurate blood pressure readings. A tight sleeve would cause congestion of blood and possibly inaccurate readings.

9. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 to 5 cm (1 to 2 in) above the inner aspect of the elbow. Line up the artery marking on the cuff with the patient's brachial artery. The tubing should extend from the edge of the cuff nearer the patient' Obtaining Blood Pressure Measurement-Stethoscope - ANS: 16. Assume a position that is no more than 3 ft away from the gauge. A distance of more than about 3 ft can interfere with accurate reading of the numbers on the gauge.
10. Place the stethoscope earpieces in your ears. Direct the earpieces forward into the canal and not against the ear itself.

It is recommended that blood pressure measurements should be checked in both arms at the first examination (Pickering et al., 2005). Most people have differences in blood pressure readings between arms. When there is a consistent interarm difference, use the arm with the higher pressure (Pickering et al., 2005). If you have difficulty hearing the blood pressure sounds, raise the patient's arm, with cuff in place, over his or her head for 30 seconds before rechecking the blood pressure. Inflate the cuff while the arm is elevated, and then gently lower the arm while continuing to support it. Position the stethoscope and deflate the cuff at the usual rate while listening for Korotkoff sounds. Raising the arm over the head reduces vascular volume in the limb and improves blood flow to enhance the Korotkoff sounds (Pickering et al., 2005). Blood pressure can be assessed using an automatic electronic blood pressure monitor or Doppler ultrasound (see the accompanying Skill Variation). Many versions of automatic electronic blood pressure monitors are not recommended for patients with irregular heart rates, tremors, or the inability to hold the extremity still. The presence of these conditions may cause the monitor to incorrectly overinflate the cuff, causing pain for the patient. Check the manufacturer's guidelines when considering use with these patients. Diastolic pressure measured while the patient is sitting is approximately 5 mm Hg higher than when measured while the patient is supine; systolic pressure measured while the patient is supine is approximately 8 mm Hg higher than when measured in the patient who is sitting (Pickering et al., 2005). Measuring blood pressure in the forearm by auscultating the radial artery for the Korotkoff sounds is becoming more common. Forearm measurements tend to be Infant and Child Considerations - ANS: Infant and Child Considerations In infants and small children, the lower extremities are commonly used for blood pressure monitoring. The more common sites are the popliteal, dorsalis pedis, and posterior tibial. Blood pressures obtained in the lower extremities are generally higher than if taken in the upper extremities. In children over 1 year of age, the systolic pressure in the thigh tends to be 10 to 40 mm Hg higher than in the arm; the diastolic pressure remains the same (Kyle & Carman, 2017). Infants and children presenting with cardiac complaints may have blood pressures assessed in all four extremities. Large differences among blood pressure readings can indicate heart defects. The fifth Korotkoff sound corresponds to diastolic blood pressure in children. In some children, the Korotkoff sounds continue to 0 mm Hg. In this situation, document the reading as systolic pressure over "P" for pulse (Kyle & Carman, 2017). Home Care Considerations - ANS: Home Care Considerations

Automated blood pressure devices in public locations are generally inaccurate and inconsistent. In addition, the cuffs on these devices are inadequate for people with large arms (Pickering et al., 2005). Explain to the patient that it is important to use a cuff size appropriate for limb circumference. Inform the patient that cuff sizes range from a pediatric cuff to a large thigh cuff and that a poorly fitting cuff can result in an inaccurate measurement. Inform the patient about digital blood pressure monitoring equipment. Although more costly than manual cuffs, most provide an easy-to-read recording of systolic and diastolic measurements. Explain that three readings, at least 1 minute apart, should be taken while in a sitting position, both in the morning and at night. Measurement should occur after resting quietly in a chair for 3 to 5 minutes, with the upper arm at heart level. The readings should be recorded to show to the health care provider. Explain that home monitoring devices should be checked for accuracy every 1 to 2 years. Readings should be compared with auscultated measurement by a health care provider to ensure accuracy.