- Where would the procedures and treatments directed by the health care provider be found?
| a. | Summary sheet |
| b. | Physician’s order form |
| c. | Physician’s progress notes |
| d. | History and physical examination form |
ANS: B
The physician’s order form contains all procedures and treatments ordered by the health care provider. A summary sheet provides a brief overview of the hospital course at discharge. Physician’s progress notes provide regular observations on the patient’s course of treatment and response. A history and physical examination form provides information about baseline information from the patient.
DIF: Cognitive Level: Knowledge REF: Page 61 OBJ: 2
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Clinical Judgment
- Which action will the nurse take when it is determined that the narcotic count is incorrect while obtaining a medication from the narcotic area?
| a. | Determine the cause of the discrepancy at the end of the shift. |
| b. | Notify the health care provider stat. |
| c. | Call the nurse from the previous shift to determine if there was a discrepancy earlier. |
| d. | Report the discrepancy to the charge nurse immediately. |
ANS: D
Reporting the discrepancy to the charge nurse immediately enables the supervisory staff to narrow the time frame during which a medication was taken and not documented. The discrepancy needs to be addressed immediately, and therefore determining the cause of the discrepancy at the end of the shift is not the most appropriate action for the nurse to take. It is not appropriate to contact the health care provider for an incorrect narcotic count. The count would have been verified at shift change; calling the nurse from the previous shift is not an appropriate action for the nurse to take.
DIF: Cognitive Level: Analysis REF: Page 70 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which action will the nurse take if a dosage is unclear on a health care provider’s order?
| a. | Ask the patient what dosage was given in the past. |
| b. | Ask another physician to determine the correct dosage. |
| c. | Tell the patient that the medication will not be given. |
| d. | Contact the health care provider to verify the correct dosage. |
ANS: D
Any questionable orders should be verified by the health care provider who wrote the orders. The patient is not a reliable source of verification. The physician who wrote the order should verify it. It would be a medication error to withhold the dose instead of verifying it.
DIF: Cognitive Level: Application REF: Page 76 | Page 77
OBJ: 5 TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- What is the most reliable method to calculate a pediatric patient’s medication dosage?
| a. | Age |
| b. | Height |
| c. | Body surface area (BSA) |
| d. | Placement on a growth scale |
ANS: C
The most reliable method is by proportional amount of BSA or body weight. Because of the differences in weight among children, age is not a reliable method. Because of the differences in height among children, this is not a reliable method. Placement on a growth scale identifies how the child corresponds to other children on a percentile. Although it is determined by a specific measurement, the percentile identified would not be a specific measurement; therefore, this is not a reliable method.
DIF: Cognitive Level: Comprehension REF: Page 77 OBJ: 7
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Development
- Which medication route provides the most rapid onset of a medication but also poses the greatest risk of adverse effects?
| a. | Intradermal |
| b. | Subcutaneous (subcut) |
| c. | Intramuscular (IM) |
| d. | Intravenous (IV) |
ANS: D
IV medications are delivered directly into the bloodstream and avoid the “first pass” effect of the liver. Intradermal, subcut, and IM administration have a slower absorption rate.
DIF: Cognitive Level: Knowledge REF: Page 78 OBJ: 7
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which is known as the “fifth vital sign”?
| a. | Temperature |
| b. | Respirations |
| c. | Pain |
| d. | Pulse |
ANS: C
Pain is known as the “fifth vital sign.”
DIF: Cognitive Level: Knowledge REF: Page 63 OBJ: 8
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Pain
- Which is true regarding the unit dose drug distribution system?
| a. | The inventory is delivered to each nursing unit on a regular and recurring basis. |
| b. | The system delivers one dose of each medication to be administered until the subsequent delivery of inventory. |
| c. | The use of single dose packages of drugs dispensed to fill each dose requirement as it is ordered. |
| d. | The amount of inventory needed to dose all patients on the unit for a 24-hour interval. |
ANS: C
The unit dose drug distribution system uses single unit packages of drugs dispensed to fill each dose requirement as it is ordered.
DIF: Cognitive Level: Comprehension REF: Page 68 OBJ: 2
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- The nursing assessment identifies that the client is nauseated and cannot take acetaminophen (Tylenol) orally. Which is true regarding the substitution of this medication to suppository form?
| a. | It is standard practice when the patient is unable to take the ordered medication. |
| b. | It is acceptable if the patient agrees to the altered route form. |
| c. | It is preferable to having the patient miss a dose of the medication. |
| d. | It is contraindicated without an order from the health care provider. |
ANS: D
One dosage form of medication should never be substituted for another unless the prescriber is consulted; there can be a great variation in the absorption rate of the medication through different routes of administration. The substitution of one form for another is not standard practice and is not acceptable or preferable without the prescriber’s order.
DIF: Cognitive Level: Application REF: Page 77 | Page 78
OBJ: 1 TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which medication order requires nursing judgment and means “administer if needed”?
| a. | Morphine 4 mg IV stat |
| b. | Morphine 4 mg IV prior to procedure |
| c. | Morphine 4 mg IV four times a day |
| d. | Morphine 4 mg IV every 4 hours PRN |
ANS: D
PRN indicates for the nurse to administer morphine every 4 hours if needed and requires nursing judgment. Stat means the dose of morphine would be given immediately, not as needed. The orders for the dose of morphine to be given prior to the patient’s scheduled procedure and four times a day do not indicate to give the dose as needed.
DIF: Cognitive Level: Comprehension REF: Page 73 OBJ: 4 | 8
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- What is medication reconciliation?
| a. | Comparing the patient’s current medication orders to all of the medications actually being taken |
| b. | The administration of high alert medications that have been ordered on admission to an acute care facility |
| c. | The completion of an incident report following a variance that resulted in a serious complication |
| d. | A printout of computerized patient data that identifies the times that all of the ordered medications are to be administered |
ANS: A
Medication reconciliation is the process of comparing a patient’s current medication orders to all of the medications that the patient is actually taking. Administering high alert medications and completing an incident report are not the same as medication reconciliation. A printout of computerized patient data that identifies the times that all of the ordered medications are to be administered is a description of the medication administration record (MAR), not a description of medication reconciliation.
DIF: Cognitive Level: Knowledge REF: Page 74 OBJ: 2 | 6 | 8
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination; Health Promotion
- Which example best demonstrates safe drug administration by the nurse?
| a. | Administering an oral medication with the patient sitting upright |
| b. | Asking children to say their name before administering the medication |
| c. | Leaving the medications on the bedside stand after verifying patient identification |
| d. | Returning the unused portion of a medication to a stock supply bottle |
ANS: A
Sitting the patient upright for oral medications is safe medication practice. Children should never be asked their names as a means of positive identification. Remaining with a patient until the drug is swallowed is safe practice. Returning an unused portion of medication to the stock supply bottle is not safe medication practice.
DIF: Cognitive Level: Application REF: Page 79 OBJ: 7
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- The nurse determines that a prescribed medication has not been administered as ordered on the previous shift. What action will the nurse take?
| a. | Administer the medication immediately. |
| b. | Complete an incident report. |
| c. | Notify the nurse responsible for the error. |
| d. | Record the occurrence in the nurse’s notes. |
ANS: B
An incident report is completed when a medication error occurs. Depending on the medication and frequency of administration, the medication may not be given immediately. It is not the nurse’s responsibility to notify another nurse of the error. Medication errors are not recorded in the nurse’s notes.
DIF: Cognitive Level: Application REF: Page 75 OBJ: 1 | 8
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- A patient’s liquid cough medicine has been discontinued with one half of the bottle remaining. The home health nurse is aware that according to the U.S. Food and Drug Administration (FDA) guidelines on prescription medication disposal, the next step should be to
| a. | save the remainder for another patient with the same prescription. |
| b. | flush the remainder down the toilet. |
| c. | read the drug label for specific disposal instructions. |
| d. | pour remaining medication into a hazardous waste container. |
ANS: C
The nurse must follow specific disposal instructions on the drug label or in the patient information leaflet that accompanies the medication. Prescription medications should not be shared among patients. Prescription drugs should not be flushed down the toilet unless specifically instructed to do so by the manufacturer. The first action to be taken is to follow disposal instructions on the label. If the drug label indicates it should be emptied into a hazardous waste container, measures should be taken to prevent leaking and/or accidental ingestion.
DIF: Cognitive Level: Analysis REF: Page 72 OBJ: 6 | 7
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety
MULTIPLE RESPONSE
- Who defines the standards of care for the practice of nursing? (Select all that apply.)
| a. | State boards of nursing |
| b. | Hospital policy and procedures |
| c. | Federal laws regulating health care facilities |
| d. | The Joint Commission |
| e. | Professional nursing associations |
ANS: A, C, D, E
Standards of care are defined by state boards of nursing, federal laws regulating health care facilities, The Joint Commission, and professional nursing associations such as the American Nurses Association. Individual hospital policies and procedures incorporate federal and state guidelines into their respective policies and procedures and are often more stringent than state and federal regulations.
DIF: Cognitive Level: Knowledge REF: Page 60 OBJ: 1
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Health Care Law; Health Care Organizations
- What must the nurse have before administering any medication? (Select all that apply.)
| a. | A current license to practice |
| b. | A medication order signed by a practitioner licensed with prescription privileges |
| c. | Knowledge of the medication |
| d. | Consultation with a pharmacist |
| e. | Knowledge of the client’s diagnosis |
ANS: A, B, C, E
Physicians must be licensed to prescribe medications; nurses must be licensed to administer medications. Safe medication administration includes knowledge of the medication, pathophysiology of patient diagnoses, and pharmacodynamics of the ordered medication on the pathophysiology. It is not necessary for the nurse to consult with a pharmacist each time medication is to be administered to a patient.
DIF: Cognitive Level: Comprehension REF: Page 60 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Health Care Law; Clinical Judgment
- Which advantage(s) does the unit dose drug distribution system include? (Select all that apply.)
| a. | There is decreased participation by the pharmacy. |
| b. | The pharmacist is able to analyze prescribed medications for each client for drug interactions and contraindications. |
| c. | There is less waste of medications. |
| d. | The time spent by nursing personnel preparing these medications is increased. |
| e. | Credit is given to the patient for unused medications. |
ANS: B, C, E
Because the pharmacist has a profile of all medications for each patient, he or she is able to analyze prescribed medications for each patient for drug interactions and contraindications. This is an advantage of the unit dose drug distribution system. Less waste of medications is an advantage of the unit dose drug distribution system. Because each dose is individually packaged, credit can be given to the patient for unused medications. There is increased pharmacist involvement and better use of his or her extensive drug knowledge, and nursing personnel time is decreased with this method.
DIF: Cognitive Level: Knowledge REF: Page 68 OBJ: 2
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Care Coordination; Safety; Health Policy
- Which statement(s) is/are true regarding the types of medication orders? (Select all that apply.)
| a. | Stat orders are the same as single dose orders. |
| b. | Standing orders indicate the number of specified doses of a medication to be given. |
| c. | Renewal orders facilitate physician review before continuance of high-risk medications. |
| d. | PRN medications will designate a mandatory number of times the medication is to be administered. |
| e. | Verbal orders should be used as much as possible. |
ANS: B, C
Standing orders state the frequency of medication dosages to be administered or indicate the time frame of administration. Renewal orders require the physician to review medications that have “expired orders,” as determined by facility policy. Renewal policies facilitate physician verification of the necessity to continue a medication beyond a “usual” time frame and help ensure patient safety. Single dose and stat orders are not the same. PRN medications are not ordered a mandatory number of times, although a maximum number might be specified. Verbal orders should be avoided whenever possible.
DIF: Cognitive Level: Comprehension REF: Page 72 | Page 73
OBJ: 1 | 8 TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Health Care Policy
- Which statement(s) is/are true regarding computerized prescriber order entry (CPOE)? (Select all that apply.)
| a. | Integrates the ordering system with the pharmacy, laboratory, and nurses’ stations |
| b. | Provides instant access to online information to facilitate patient care needs |
| c. | Facilitates review of ordered medications for potential drug interactions |
| d. | Facilitates review of drugs for appropriateness of dosages |
| e. | Alleviates the need to perform mathematical computations |
ANS: A, B, C, D
CPOE systems integrate patient information, provide instant access, facilitate review of ordered medications for potential drug interactions, and facilitate review of drugs for appropriateness of dosages. Alleviation of the need to perform mathematical computations is not a component of the CPOE system.
DIF: Cognitive Level: Knowledge REF: Page 68 | Page 69
OBJ: 1 | 8 TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity| NCLEX Client Needs Category: Safe, Effective Care Environment
NOT: CONCEPT(S): Clinical Judgment; Safety; Care Coordination; Technology and Informatics
- Which lab test(s) would be used to assess liver and/or renal function before administering medications? (Select all that apply.)
| a. | CBC |
| b. | LDH |
| c. | ALT |
| d. | Crs |
| e. | BUN |
| f. | aPTT |
ANS: B, C, D, E
Liver function tests include LDH (lactic dehydrogenase) and ALT (alanine aminotransferase). Renal function tests include Crs (serum creatinine) and BUN (blood urea nitrogen). Although a CBC (complete blood count) and an aPTT are useful in assessing the patient before administration of medication, they are not renal or hepatic function tests.
DIF: Cognitive Level: Knowledge REF: Page 76 | Page 77
OBJ: N/A TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion
- The nurse is preparing to administer Lanoxin to a patient on the telemetry unit. In addition to understanding the patient’s diagnosis, the nurse must also know which characteristic(s) of the medication? (Select all that apply.)
| a. | Chemical composition |
| b. | Adverse effects |
| c. | Expected actions |
| d. | Contraindications for use |
| e. | Usual dosing |
ANS: B, C, D, E
The nurse must understand the individual patient’s diagnosis and symptoms that correlate with the rationale for drug use. The nurse should also know why a medication is ordered, expected actions, usual dosing, proper dilution, route and rate of administration, adverse effects, and contraindications for the use of a particular drug. It is not required that the nurse know the chemical composition of the medication prior to administration.
DIF: Cognitive Level: Application REF: Page 73 | Page 76
OBJ: 6 TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety
- The nurse transcribes an order to administer Valium 10 mg IV stat. This order is correctly interpreted by the nurse to mean it should be provided how? (Select all that apply.)
| a. | As needed |
| b. | Immediately |
| c. | One time only |
| d. | In divided doses |
| e. | Intravenously |
ANS: B, C, E
The stat order is generally used on an emergency basis. It means that the drug is to be administered as soon as possible, but only once. IV indicates the route is intravenous. A PRN order means “administer if needed.” The order would specify “divided doses” and amount per dose if indicated.
DIF: Cognitive Level: Analysis REF: Page 72 OBJ: 8
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
Chapter 07: Percutaneous Administration
Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition
MULTIPLE CHOICE
- A patient has an infected wound with large amounts of drainage. Which type of dressing would the nurse use?
| a. | Telfa |
| b. | OpSite |
| c. | DuoDerm |
| d. | AlgiDERM |
ANS: D
AlgiDERM is manufactured from seaweed and is recommended for infected wounds because it is an exudate absorber. Telfa and OpSite do not absorb exudates. DuoDerm is for light to moderate wound drainage. According to the manufacturer, it does absorb exudates, but it is best for wounds with moderate drainage.
DIF: Cognitive Level: Comprehension REF: Page 83 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Tissue Integrity; Infection
- Where would the nurse apply nitroglycerin ointment on a male patient?
| a. | The same site that was previously used |
| b. | A hairy area of the chest |
| c. | The upper arm |
| d. | The back of the knee |
ANS: C
Any area without hair may be used. Most people prefer the chest, flank, or upper arm areas. Sites should be rotated. The back of the knee is not suitable for applying medication because of the joint motion and difficulty of keeping a dressing in place.
DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Where will the nurse administer a medication that was ordered to be given sublingually?
| a. | Between the molar teeth and cheek |
| b. | Below the skin surface |
| c. | Under the tongue |
| d. | Into the conjunctival sac |
ANS: C
The sublingual area is underneath the tongue. Between the molar teeth and cheek is the buccal area. Medication administered below the skin surface is intradermal administration. The conjunctival sac is between the eyelids and eyeball.
DIF: Cognitive Level: Knowledge REF: Page 88 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Why are sublingual and buccal medications rapidly absorbed?
| a. | Their action is localized to the mouth. |
| b. | They are metabolized in the liver. |
| c. | Blood flow is diminished in these sites. |
| d. | These drugs pass directly into systemic circulation. |
ANS: D
Sublingual medications are rapidly absorbed into systemic circulation because of the increased blood flow to these areas and avoid the “first pass” effect of the liver where extensive metabolism usually takes place. These routes do not contain drug effects to the oral area and they bypass the liver. These sites are highly vascular.
DIF: Cognitive Level: Comprehension REF: Page 88 OBJ: 5
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which medications must be sterile?
| a. | Topical |
| b. | Vaginal |
| c. | Ophthalmic |
| d. | Nasal |
ANS: C
Ophthalmic (eye) medications must be sterile. Topical, vaginal, and nasal applications do not need to be sterile.
DIF: Cognitive Level: Knowledge REF: Page 89 OBJ: N/A
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which action will the nurse perform when doing a wet to dry dressing every 4 hours on a patient with a deep wound?
| a. | Pack the wound tightly with gauze. |
| b. | Saturate the dressing with as much liquid as possible. |
| c. | Use Montgomery tapes or a binder to secure the dressing. |
| d. | Apply the new moist dressing over the existing one. |
ANS: C
The use of Montgomery tapes or a binder reduces the irritation of nearby skin tissue. The dressing should be packed into the wound loosely. The dressings should be wrung out to prevent dripping. The previous dressing should always be completely removed.
DIF: Cognitive Level: Application REF: Page 83 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- When applying nitroglycerin topically, which nursing intervention is correct?
| a. | Secure the paper on two sides with tape. |
| b. | Shave the area prior to application of the paper. |
| c. | Wear gloves while placing the new paper. |
| d. | Remind the patient to discontinue use of the medication if chest pain is relieved. |
ANS: C
Wearing gloves prevents accidental exposure to the medication. The area where the paper is placed should be covered with plastic wrap and taped into place to prevent medication from seeping out. Shaving may cause skin irritation. The dosage and frequency of application should be gradually reduced over 4 to 6 weeks, and the patient should contact the health care provider if adjustment is desired.
DIF: Cognitive Level: Application REF: Page 86 | Page 87
OBJ: 3 TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Where does the nurse correctly administer ophthalmic medication?
| a. | At the inner canthus of the eye |
| b. | In the lower conjunctival sac |
| c. | Directly onto the eyeball |
| d. | To the outer corner of the eyelid |
ANS: B
The lower conjunctival sac is exposed by applying gentle traction to the lower lid at the bony rim of the orbit. The inner canthus allows medication to flow out of the eye. Applying directly to the eyeball risks injury to the globe. The outer corner of the eyelid allows medication to flow out of the eye.
DIF: Cognitive Level: Knowledge REF: Page 89 OBJ: N/A
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which effect would be important for the nurse to address when teaching a patient about the overuse of nose drops?
| a. | Rebound |
| b. | Ceiling |
| c. | Idiosyncratic |
| d. | Measured |
ANS: A
Rebound effect may occur with overuse of some medications. Ceiling effect is the greatest attainable response. An idiosyncratic effect may occur even with prudent use of nose drops. Measured effect is the patient’s response to the medication.
DIF: Cognitive Level: Application REF: Page 93 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion
- Which nursing assessment accurately describes the results of an intradermal skin test?
| a. | Itching and weeping |
| b. | Erythema and induration |
| c. | Swelling and coolness |
| d. | Pallor and drainage |
ANS: B
The result should be measured by diameter of erythema in millimeters, and the induration should be palpated and measured in millimeters. Itching is not relevant to the results; weeping should be reported to the health care provider but is not pertinent to the evaluation of the skin test. Swelling, coolness, pallor, and drainage are not relevant to evaluation; reporting this to the health care provider is appropriate but not pertinent to the evaluation of the skin test.
DIF: Cognitive Level: Comprehension REF: Pages 83-85 OBJ: 2
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment
- The nurse is teaching a patient about nitroglycerin ointment. Which is an advantage of this form of the medication?
| a. | It does not give the patient a bad taste in the mouth. |
| b. | The amount of ointment does not matter in obtaining a therapeutic response. |
| c. | It does not cause headaches as an adverse effect. |
| d. | It provides relief of anginal pain for several hours longer than sublingual medication. |
ANS: D
Nitroglycerin ointment provides relief of anginal pain for several hours longer than sublingual preparations. Nitroglycerin pills do not have a bad taste. Dosage is critical to the success of use. All nitroglycerin preparations may cause headaches because of vasodilation.
DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 3
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Pain; Health Promotion
- A patient with metastatic cancer is being admitted for pain control. Which action will the nurse perform in administering a transdermal patch?
| a. | After removal, dispose of the old patch in a receptacle in the patient’s room. |
| b. | Change the fentanyl patch every day, either in the morning or at bedtime. |
| c. | Hold the short-acting oral pain medication when a fentanyl patch is initiated. |
| d. | Label the patch with date, time, dosage, and initials after patch placement. |
ANS: D
Labeling is appropriate when transdermal disks are placed. Patches are to be disposed of in a receptacle on the medication cart, not in the patient’s room. Fentanyl patches are changed every 72 hours. Fentanyl patches take up to 12 hours to be effective; therefore, short-acting pain medication is continued.
DIF: Cognitive Level: Application REF: Page 87 OBJ: 4
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Pain; Safety
- What is the rationale for the nurse applying gentle pressure to the inner corner of the eyelid after instilling eyedrops?
| a. | Decreases the risk of infection |
| b. | Maintains intraocular pressure |
| c. | Prevents systemic effects |
| d. | Provides comfort to the patient |
ANS: C
Application of pressure to the inner corner of the eye prevents the medication from entering the canal, where it would be absorbed in the vascular mucosa of the nose and produce systemic effects. Application of pressure to the inner corner of the eye does not decrease infection, maintain intraocular pressure, or promote patient comfort.
DIF: Cognitive Level: Application REF: Page 90 OBJ: N/A
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- The nurse is instructing a patient to use a corticosteroid inhaler. Which statement by the patient indicates the need for further teaching?
| a. | “I will shake the inhaler before I use it.” |
| b. | “I need to rinse my mouth after I use the inhaler.” |
| c. | “I will use this when I’m lying in bed in the morning.” |
| d. | “After I inhale, I will hold my breath and then breathe out slowly.” |
ANS: C
The sitting position allows for maximum lung expansion. Shaking the inhaler helps to disperse the medication. The mouth needs to be rinsed after the inhalation of a corticosteroid. Holding the breath then exhaling slowly allows the drug to settle into pulmonary tissue.
DIF: Cognitive Level: Application REF: Page 94 OBJ: 7
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion
- What is the appropriate nursing action when administering a vaginal suppository?
| a. | Ask the patient to urinate prior to insertion. |
| b. | Assist the patient to a side-lying position. |
| c. | Keep suppository refrigerated prior to insertion. |
| d. | Insert the suppository 1 inch into the vagina. |
ANS: A
An empty bladder facilitates insertion. A side-lying position would not facilitate insertion of a vaginal suppository. The suppository needs to be warmed to room temperature before it is administered. The suppository is inserted more than 1 inch.
DIF: Cognitive Level: Application REF: Page 97 OBJ: 8
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which is an accurate nursing action when treating a patient’s rash with a lotion?
| a. | Avoid shaking the container prior to application. |
| b. | Cleanse area with alcohol prior to treatment. |
| c. | Cover the area with gauze because of the oil base. |
| d. | Pat on the area with a gloved hand. |
ANS: D
To prevent increased circulation and itching, lotions should be gently but firmly patted on the skin, rather than rubbed in. Shake all lotions thoroughly immediately before application. Lotions are aqueous and are easily cleansed with water. Lotions are not oil based.
DIF: Cognitive Level: Application REF: Page 81 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- A 2-year-old child is hospitalized with the diagnosis of tonsillitis and bilateral otitis media. The nurse is preparing to administer eardrops. When instilling the eardrops, the nurse will pull the earlobe
| a. | upward and back. |
| b. | sideways and down. |
| c. | downward and back. |
| d. | sideways and up. |
ANS: C
For children under 3 years, pull the earlobe downward and back with eardrop instillation to straighten the external auditory canal. The earlobe is pulled up and back for adults and children ages 3 and over.
DIF: Cognitive Level: Comprehension REF: Page 91 OBJ: 6
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Development
- The nurse is preparing an otic solution. When instructing the patient in regard to area of administration, the nurse will explain that the solution will be placed
| a. | into the eye. |
| b. | under the tongue. |
| c. | topically. |
| d. | into the ear. |
ANS: D
Medications for use in the ear are labeled otic. Ophthalmic solutions are administered into the eye. Sublingual medications are administered under the tongue. Topical medications are applied to the skin.
DIF: Cognitive Level: Application REF: Page 91 OBJ: 6
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education
MULTIPLE RESPONSE
- Which order(s) would be examples of percutaneous medication administration? (Select all that apply.)
| a. | Timolol 0.5% 1 drop to each eye daily |
| b. | Albuterol nebulizer 2.5 mg qid |
| c. | Heparin 5000 units IV |
| d. | Lasix 20 mg PO every AM |
| e. | Silvadene 1% topically to affected area |
ANS: A, B, E
Percutaneous administration refers to applying medications to the skin or mucous membranes for absorption, such as eyedrops.
DIF: Cognitive Level: Application REF: Page 81 OBJ: 1 | 7
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety
- Which action(s) will the nurse perform when preparing to administer a topical medication? (Select all that apply.)
| a. | Wash hands before and after administration. |
| b. | Maintain a dry environment to encourage wound healing. |
| c. | Wear gloves during the application process. |
| d. | Use sterile dressings for all wounds. |
ANS: A, C
Handwashing is an essential part of medication administration. Gloves are worn with topical medication to prevent absorption into the practitioner’s own skin. Dryness does not encourage wound healing. Sterile dressings do not work well for all wounds.
DIF: Cognitive Level: Application REF: Page 82 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion
- Which dressings would be appropriate to use for treating wounds with exudates? (Select all that apply.)
| a. | AlgiDERM |
| b. | Telfa |
| c. | Kaltostat |
| d. | Sorbsan |
| e. | OpSite |
ANS: A, C, D
AlgiDERM, Kaltostat, and Sorbsan are exudate absorbers for use in treating infected wounds. Telfa and OpSite are not appropriate to use on wounds with exudates.
DIF: Cognitive Level: Knowledge REF: Page 82 OBJ: 1
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion
ORDERING
- Place the following steps for administration of nose drops in the correct order. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.)
- Draw medication into the dropper.
- Instruct patient to blow the nose gently.
- Review practice setting policy.
- Explain the steps to the patient.
- Position the patient into supine position with head backward over edge of bed.
- Instill medication.
ANS:
C, D, B, E, A, F
DIF: Cognitive Level: Analysis REF: Page 92 OBJ: 5
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion; Patient Education
