Medication And I.V. Administration (Part 1)

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1. A nurse is delivering a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take?

Explanation

RATIONALE: Whenever a client isn't immediately available to take medication, the nurse should put the medicine in a secured area. The nurse should never leave drugs unattended in a client's room or in the care of a roommate. The nurse shouldn't omit doses of medication without a physician's order.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 784.

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About This Quiz
Medication And I.V. Administration (Part 1) - Quiz

Some medications must be given by an intravenous (IV) injection, they're sent directly into your veins using a needle or tube. A medical practitioner needs to know exactly which types of medication are administered via IV and the circumstances. The test below will review what you know about this so... see morefar. All the best! see less

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2. Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion?

Explanation

RATIONALE: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client how long the transfusion will take and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess the client's vital signs at least hourly during the transfusion, not just at the conclusion of the transfusion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1739.

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3. After knee replacement surgery, a client is being discharged with acetaminophen and codeine tablets, 30 mg, for pain. During discharge preparation, the nurse should include which instruction?

Explanation

RATIONALE: Clients taking codeine should avoid driving because the medication can impair mental alertness. Fluid restriction isn't indicated, especially after surgery. To prevent adverse GI effects such as nausea, vomiting, anorexia, and constipation, the client shouldn't take codeine on an empty stomach. Codeine may cause dizziness, drowsiness, and seizures but doesn't cause fine motor tremors.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 359.

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4. A client is being discharged after cataract surgery. After providing medication teaching, the nurse asks the client to repeat the instructions. This approach is an example of which professional role?

Explanation

RATIONALE: When teaching a client about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making client care assignments. The nurse acts as a caregiver when providing direct care, including bathing clients and administering medication and prescribed treatments. She acts as a client advocate when making the client's wishes known to the physician.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 18.

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5. A client is in the bathroom when a nurse enters to give him a prescribed medication. What should the nurse do?

Explanation

RATIONALE: The nurse should return to the client's room a few minutes later and remain there until she can verify that the client has taken the medication as directed. A nurse should never leave medication at the client's bedside.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 566.

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6. A nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure?

Explanation

RATIONALE: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to facilitate the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position or has poor sphincter control, the nurse may position him in the dorsal recumbent or right lateral position. The supine and prone positions are inappropriate for this procedure and uncomfortable for the client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1587.

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7. A nurse is teaching a client about a newly ordered drug. What could cause an elderly client to have difficulty learning about ordered medications?

Explanation

RATIONALE: Sensory deficits could cause a geriatric client to have difficulty retaining knowledge about ordered medications. Decreased drug excretion doesn't alter the client's knowledge about the drug. A lack of family support or limited finances may affect compliance, not knowledge retention.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 775.

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8. A nurse receives a medication order over the telephone. What is the best way for the nurse to handle this situation?

Explanation

RATIONALE: When taking a medication order over the telephone, standard practice requires verbal verification of the order and the physician's written signature within 24 hours. The nurse practice act doesn't prohibit taking medication orders over the telephone. Having a second physician repeat the order opens another avenue for misinterpretation and error. Insisting that the physician sign the order within 1 hour is unrealistic.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 254.

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9. When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:

Explanation

RATIONALE: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90-degree angle when giving a subcutaneous injection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice,8th ed. Lippincott Williams & Wilkins, 2007, p. 47.

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10. Before administering packed red blood cells, a nurse must flush a client's I.V. line. Which solution should the nurse use to flush the line?

Explanation

RATIONALE: Normal saline solution is the only I.V. solution that is compatible with any blood product. Lactated Ringer's and dextrose solutions are incompatible with blood products.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1737.

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11. After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom she's assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?

Explanation

RATIONALE: Most facilities require photo identification to maintain security and confidentiality. Allowing a student without an ID to have supervised access to a medication record doesn't protect client information. Contacting the instructor by phone doesn't verify the student's identity.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R., and Hirnle, C. Fundamentals of Nursing: Human Health and Function, 5th ed. Lippincott Williams & Wilkins, 2007, p. 256.

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12. When teaching a client how to take a sublingual tablet, the nurse should instruct the client to place the tablet:

Explanation

RATIONALE: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth, then place the sublingual tablet on the floor of the mouth. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa, bypassing the GI and hepatic systems. No drug is administered on top of the tongue or on the roof of the mouth. With the buccal route, the client places the tablet between the gum and the cheek.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 791.

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13. Which I.M. injection site is appropriate for a 6-month-old infant?

Explanation

RATIONALE: A nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. She should give the injection in the ventrogluteal area only in a child who has been walking for about 1 year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 798.

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14. Which human element should a nurse consider during assessment of home drug administration?

Explanation

RATIONALE: The nurse must consider the client's cognitive abilities to understand drug instructions. If the client can't understand the instructions, the nurse must find a family member or significant other to take on the responsibility of administering medications in the home setting. The client's ability to recover, occupational hazards, and socioeconomic status don't affect drug administration.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 11.

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15. When administering drug therapy to an elderly client, the nurse must remain especially alert for adverse effects. Which factor makes elderly clients more vulnerable than younger clients to adverse drug effects?

Explanation

RATIONALE: Aging-related physiologic changes account for the increased frequency of adverse drug reactions in elderly clients. Renal and hepatic changes cause drugs to clear more slowly in these clients. With increasing age, the number of neurons and blood flow to the GI tract decrease.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 86.

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16. A nurse prepares to administer medication by the buccal route. Where should the nurse place this medication?

Explanation

RATIONALE: The nurse should place medication administered by the buccal route in the client's upper or lower buccal pouch, between the cheek and gum. She should apply a topical medication to the client's skin; place a sublingual medication under his tongue on the floor of the mouth; and administer an eye (ocular) medication in the conjunctival sac.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 791.

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17. A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?

Explanation

RATIONALE: A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 555.

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18. A physician orders morphine, 3 mg I.V. every 2 hours as needed, to control a client's postoperative pain. The package insert reads: "Morphine, 4 mg/ml." How many milliliters of morphine should the client receive?

Explanation

RATIONALE: To determine the number of milliliters of morphine the client should receive, the nurse should use the fraction method in the following equation:
3 mg/X ml = 4 mg/1 ml
To solve for X, cross-multiply:
3 mg × 1 ml = X ml × 4 mg
3 = 4X
3/4 = X
0.75 ml = X

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 56.

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19. A physician orders ampicillin (Omnipen), 500 mg by mouth every 6 hours. This medication order is an example of:

Explanation

RATIONALE: A standing order applies until the prescriber writes another order to alter or discontinue the first one. Many health care facilities have established policies dictating how long orders for certain classes of drugs, such as opioids or antibiotics, are to remain valid. A single order allows a one-time dose only. An as-needed order allows a nurse to administer the drug whenever the client needs it. A stat order includes such words as now, immediately, or stat.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 554.

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20. A nurse is caring for a client who is taking an oral anticoagulant. The nurse should teach the client to:

Explanation

RATIONALE: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. The client may need to report diarrhea, but anticoagulants don't cause diarrhea. The client should use an electric razor — not a straight razor — to prevent cuts that bleed. Aspirin may increase the risk of bleeding; the client should use acetaminophen for pain relief.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 889.

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21. While preparing to start a stat I.V. infusion, a nurse notices a broken ground on the infusion pump's plug. What should the nurse do first?

Explanation

RATIONALE: Because safety is imperative for both the nurse and her client, the nurse should obtain another pump. Using the pump as is could lead to electric shock. The nurse should never use damaged equipment, even after performing a temporary repair. She should label damaged equipment "Broken" and report it to the appropriate department for repair.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 685.

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22. A nurse is to give a client an I.V. infusion of 3,000 ml of dextrose and normal saline solution over 24 hours. She observes that the infusion rate is 150 ml/hour. If the solution runs continuously at this rate, the infusion will be completed in:

Explanation

RATIONALE: The total amount to be given, 3,000 ml, divided by the hourly rate, 150 ml/hour, equals the length of the infusion or, in this case, 20 hours.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 56.

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23. A nurse is preparing to administer a sustained-release capsule to a client. Which is an appropriate nursing intervention?

Explanation

RATIONALE: Sustained-release capsules should never be split open, crushed, or chewed because doing so may alter the drug's absorption rate, causing adverse reactions or subtherapeutic activity. Sustained-released capsules should be swallowed whole.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 567.

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24. Before administering the evening dose of an ordered medication, a nurse on the evening shift finds an unlabeled, filled syringe in a client's medication drawer. What should the nurse do?

Explanation

RATIONALE: As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe practices because they promote error.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 784.

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25. The physician orders milk of magnesia, 2 teaspoons by mouth as needed, for a constipated client. How many milliliters should the nurse administer to the client?

Explanation

RATIONALE: One teaspoon equals 5 ml. Therefore, to administer the correct amount of medication, the nurse should administer 10 ml.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 56.

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26. An elderly client who experiences several adverse drug reactions may benefit from:

Explanation

RATIONALE: In older clients, diminished hepatic and renal function commonly reduces drug metabolism and excretion. Because adverse reactions are frequently related to drug blood level, the client may benefit from reduced drug dosages. Adverse drug reactions don't represent a reason for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the client's body reacts to the drug.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 774.

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27. A physician orders an I.V. bolus injection of diltiazem hydrochloride (Cardizem) for a client with uncontrolled atrial fibrillation. What should the nurse do before administering an I.V. bolus?

Explanation

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 857.

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28. When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?

Explanation

RATIONALE: The nurse should report the information to the physician because the client's safety may be endangered. She shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving him another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 566.

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29. When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Explanation

RATIONALE: A nurse maintaining a central venous catheter should change the dressing every 72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the nurse should use sterile technique to clean around the site in accordance with facility policy. After the cleaning solution has dried, the nurse should cover the site with a transparent semipermeable dressing. A nurse who notes drainage on a wound dressing should draw a circle around the moist spot and note the date and time. She should notify the physician if she observes any catheter-related complications. Only a nurse with the appropriate qualifications may remove a central venous catheter, and a moist or loose dressing isn't a reason to remove the catheter.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1005.

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30. For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate?

Explanation

RATIONALE: The most appropriate action is to call the physician to request an oral pain medication. By doing so, the nurse is adhering to the client's wishes. Administering an I.V. injection without client consent is considered battery and may result in a lawsuit. Withholding medication without providing an alternative and attempting to manipulate the client into taking the medication would violate the standards of care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 557.

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31. A physician writes a medication order for meperidine (Demerol) 500 mg. The nurse's appropriate action would be to:

Explanation

RATIONALE: The nurse must call the physician to clarify the order because meperidine 500 mg isn't a safe dosage and the physician's order is incomplete. The order doesn't include a route or frequency of administration. It isn't appropriate for the nurse to administer an unsafe dosage to the client. The nurse should clarify the order with the physician, not with the pharmacist or another nurse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 781.

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32. A client complains of difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take next?

Explanation

RATIONALE: The nurse should find out whether the medication is available in liquid form. Dissolving or breaking the capsule may interfere with drug action or absorption. The nurse shouldn't withhold any medication without first notifying the physician.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 822.

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33. What information must a medication order include?

Explanation

RATIONALE: A medication order must include a physician's signature. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions aren't components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 779.

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34. A client receiving morphine for long-term pain management develops tolerance. Tolerance is defined as:

Explanation

RATIONALE: Tolerance occurs when the body requires higher doses of substances, such as alcohol, opioids, or benzodiazepines, to achieve desired effects. Increased response indicates a need for less of a drug to achieve the same effects. Allergic reactions are autoimmune responses to a particular drug or class of drugs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1200.

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35. A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?

Explanation

RATIONALE: To administer oral medication through an NG tube, the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Making sure not to crush sustained-release tablets or empty capsules, she then inserts the liquid into the NG tube. Heating the tablets may destroy or alter the drug's action. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube, possibly providing inaccurate dosing and clogging the tube.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 790.

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36. A client is to be discharged on daily medication delivered by a transdermal disk. Which statement indicates the need for further medication teaching?

Explanation

RATIONALE: A transdermal disk should be applied to a different site each time. The client should avoid placing the disk on uneven, damaged, or irritated skin or on areas below the knee or elbow. The other options indicate that the client understands how to use the transdermal disk.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 803.

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37. When administering an I.M. injection, which action puts the nurse at risk for a needle-stick injury?

Explanation

RATIONALE: A nurse should use the one-handed needle-recapping technique only when absolutely necessary, such as when a sharps-disposal container isn't readily available. A sharps-disposal container is available in most instances. Nurses shouldn't recap needles. Choosing safety needle devices whenever possible and appropriate; planning in advance how to handle and dispose of needles; and discarding needles, safety needle systems, and sharps in sharps-disposal containers immediately after use are safe ways to handle sharps with less risk of needle-stick injuries.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R., and Hirnle, C. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 521.

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38. A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine (Intropin) therapy. What is the treatment for dopamine extravasation?

Explanation

RATIONALE: If extravasation occurs with dopamine administration, the nurse should elevate the affected limb, apply warm compresses, and administer phentolamine as ordered. She shouldn't massage the limb or apply cold compresses. Physicians don't generally order hyaluronidase for dopamine extravasation. An incision isn't required or appropriate to drain the affected area.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 152.

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39. After undergoing small-bowel resection, a client is ordered metronidazole (Flagyl) 500 mg I.V. The mixed I.V. solution contains 100 ml. The nurse is to run the drug over 30 minutes. The drip factor of the available I.V. tubing is 15 gtt/ml. What is the drip rate? Round your answer to the nearest whole number.Answer: ___ gtt/minute

Explanation

RATIONALE: Use the following equation: 100 ml/30 minutes × 15 gtt/1 ml = 49.9 gtt/minute (50 gtt/minute)

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

Submit
40. A medication order reads, "Meperidine 1 ml I.M. stat." A nurse responsible for administering the drug should base her next action on which understanding?

Explanation

RATIONALE: The nurse must clarify this order with the physician because meperidine is available in several dosage strengths, and 1 ml may contain varying amounts of the drug. A stat order need not specify a precise administration time. Meperidine is commonly given I.M. Because the order specifies the drug volume but not the dosage, the nurse shouldn't consider this order correct and valid.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 554.

Submit
41. Which instruction should a nurse give a client with prostatitis who is receiving co-trimoxazole double strength (Bactrim-DS)?

Explanation

RATIONALE: The client must drink 6 to 8 glasses of fluid daily to prevent renal problems, such as crystalluria and stone formation. If the drug is effective, symptoms should improve within a few days. Sore throat and sore mouth are adverse effects; the client should report them to a physician right away. The drug causes photosensitivity, but the client should use a PABA-free sunscreen; PABA can interfere with the drug's action.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 524.

Submit
42. When a nurse tries to administer medication, the client refuses it, saying, "I don't have to take those pills if I don't want to. What good will they do?" Which action by the nurse would be most appropriate?

Explanation

RATIONALE: By helping the client explore his feelings about his change in health status, the nurse can determine how these feelings affect his decision to refuse medication. Then the nurse can help the client develop new ways to satisfy self-care, esteem, and other needs and, ultimately, participate fully in the therapeutic regimen. Insisting that the client take the medication, reporting the client's comments to the physician, and explaining the consequences of not taking the medication are inappropriate because these actions don't explore the client's feelings.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 377.

Submit
43. After administering an I.M. injection, a nurse notices there isn't a sharps-disposal container nearby. Which action should the nurse take?

Explanation

RATIONALE: When a sharps-disposal container isn't nearby, a nurse should use the one-handed scoop technique to prevent needle-stick injury while transporting the needle to a sharps-disposal container. Scooping the needle and pushing the cap on isn't a one-handed method. The needle could puncture the cap, causing a needle-stick injury. A needle should never be disposed of in a trash container.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 718.

Submit
44. A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively?

Explanation

RATIONALE: Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 625.

Submit
45. A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about:

Explanation

RATIONALE: Tamoxifen is an estrogen blocker used to treat premenopausal and postmenopausal breast cancer and to prevent breast cancer in certain women who are at high risk. Acetaminophen is a nonopioid analgesic antipyretic. Dopamine is a vasoconstrictor used to treat hypotension. Progesterone is a hormone used to treat amenorrhea or dysfunctional uterine bleeding.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 227.

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46. A nurse administers racemic epinephrine (Racepinephrine) to an 8-year-old boy. Ten minutes after administration, the nurse should be alert for:

Explanation

RATIONALE: Racemic epinephrine can cause a rebound effect with signs of respiratory distress (tachypnea, restlessness, and cyanosis) up to 4 hours after treatment. Tachycardia may initially follow treatment with racemic epinephrine; improved oxygenation and improved color can indicate improved client status.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 907.

Submit
47. The physician orders dextrose 5% in water, 1,000 ml to be infused over 8 hours. The I.V. tubing delivers 15 drops/ml. The nurse should run the I.V. infusion at a rate of:

Explanation

RATIONALE: Giving 1,000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Find the number of milliliters per minute as follows:
125/60 minutes = X/1 minute
60X = 125 = 2.1 ml/minute.
To find the number of drops per minute:
2.1 ml/X gtt = 1 ml/15 gtt
X = 32 gtt/minute, or 32 drops/minute.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 56.

Submit
48. Which type of medication order might read "Vitamin K 10 mg I.M. daily m 3 days?"

Explanation

RATIONALE: This example is a standing order. Prescribers write a one-time order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. An as-needed order doesn't indicate a specific administration time; it gives guidelines for when to administer the medication. Many pain medication orders are as-needed orders.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 779.

Submit
49. A physician orders cefoxitin (Mefoxin), 1 g in 100 ml of 5% dextrose in water, to be administered I.V. A nurse determines that the recommended infusion time is 15 to 30 minutes. The available infusion set has a calibration of 10 drops/ml. To infuse cefoxitin over 30 minutes, which drip rate should the nurse use?

Explanation

RATIONALE: To calculate an I.V. flow rate, the nurse multiplies the number of milliliters to be infused (100 in this case) by the drop factor (10 drops/ml), and then divides by the number of minutes over which the solution is to be infused — 30 minutes. (100 × 10) ÷ 30 = 33 drops/minute

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 56.

Submit
50. When a nurse brings prescribed medication to a client, the client says she usually takes a white tablet, not the yellow tablet that the nurse has brought. What should the nurse do first?

Explanation

RATIONALE: If a client says a medication seems unusual or different, the nurse should recheck the medication name and strength. Telling the client that the white tablet must be from a different manufacturer or reassuring the client that it's the correct medication would be inappropriate because the client may be correct. If the nurse detects an error when rechecking the medication name and strength, withholding the medication and notifying the physician would be appropriate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 557.

Submit
51. A nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites?

Explanation

RATIONALE: Rotating injection sites promotes adequate drug absorption and prevents formation of hard nodules caused by repeated injections into the same site. Nodules may impede drug absorption with future injections. Rotating sites doesn't prevent bruising, medication leakage, or erratic drug distribution.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 429.

Submit
52. A client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?

Explanation

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 1010.

Submit
53. A nurse must deliver 1,000 ml of normal saline solution over 8 hours. The I.V. tubing has a drop factor of 10 gtt/ml. The nurse should set the flow rate as:

Explanation

RATIONALE: The nurse can use various methods to calculate the gtts/minute. One method is dividing the total volume by the total time in minutes, and multiplying that number by the drop factor as follows:
1,000 ml/480 minutes × 10 gtt/ml = 20.83 gtt/minute.
She should round drop factors to whole numbers because fractions of drops can't be counted. Therefore, the correct flow rate is 21 gtt/minute.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R., and Hirnle, C. Fundamentals of Nursing: Human Health and Function, 5th ed. Lippincott Williams & Wilkins, 2007, p. 613.

Submit
54. A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the 3-day limitation on the record. On the fourth day after the physician wrote the order, a nurse administers prednisone 5 mg P.O. A nurse identifies the error during a chart audit. The person most responsible for the error is the:

Explanation

RATIONALE: The nurse administering the dose should have compared the MAR with the Kardex and noted the discrepancy. The transcribing nurse and pharmacist are also responsible; however, the nurse administering the dose is most responsible. Because the facility's policy does provide for a system of checks and balances, the facility isn't responsible for the error.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 811.

Submit
55. The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. How should the nurse position the client?

Explanation

RATIONALE: To administer an I.M. injection into the vastus lateralis muscle, the nurse should position the client flat on his back (supine) or sitting upright to allow access to the muscle in the thigh. Positioning the client on his stomach would allow access to the ventrogluteal or dorsogluteal site. Positioning the client on his left or right side would allow access to the ventrogluteal site.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 798.

Submit
56. A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in his neck, mouth, and tongue. The nurse should recognize this as:

Explanation

RATIONALE: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. Mistaking the symptoms for psychotic symptoms can lead to misdiagnosis. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 169.

Submit
57. When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Explanation

RATIONALE: The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge any clots that are present. Elevating the I.V. fluid bag may help if the nurse finds no kinks and if repositioning doesn't resolve the problem.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 615.

Submit
58. When positioned properly, the tip of a central venous catheter should lie in the:

Explanation

RATIONALE: When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1706.

Submit
59. Which class of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

Explanation

RATIONALE: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the heart's workload by decreasing the heart rate. Opioids reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 296.

Submit
60. Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed?

Explanation

RATIONALE: Pregnant nurses shouldn't administer cytotoxic drugs because long-term exposure to cytotoxic drugs may be associated with teratogenic effects. Nonpregnant nurses should wear gloves while administering cytotoxic drugs. To prevent exposure and leakage, the nurse should mark all parenteral infusion containers with hazard labels and check infusion container connections before drug administration. Nurses can avoid exposure to cytotoxic drugs by priming the infusion line into gauze in a sealable bag.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 206.

Submit
61. While performing rounds, a nurse finds that a client is receiving the wrong I.V. solution. The nurse's initial response should be to:

Explanation

RATIONALE: When a client is getting the wrong I.V. solution, the nurse should maintain the access and start the proper solution. She doesn't have to remove the catheter. Doing so would subject the client to unnecessary needle sticks. Waiting until the next bottle is due is inappropriate and places the client at risk for problems and the nurse in legal jeopardy. After starting the correct solution, the nurse should complete an incident report describing the specific error.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 811.

Submit
62. An 18-year-old client is seen in the emergency department following a fall from a horse. After vigorously cleaning a large, dirty laceration on his leg, a nurse closes and dresses the wound. The client has, in the past, received the full tetanus-toxoid immunization regimen, but tells the nurse he had his last shot when he was 11 years old. The nurse should:

Explanation

RATIONALE: If a client who has a wound contaminated with soil that may contain animal excrement has completed the full childhood tetanus immunization regimen, the nurse should give him a dose of tetanus toxoid if his most recent dose was administered 3 or more years earlier. (It had been 7 years since the client's last dose.) Serum tetanus titer levels don't indicate whether the nurse should administer tetanus toxoid. No available tetanus immunization confers life-long immunity.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1053.

Submit
63. A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:

Explanation

RATIONALE: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1197.

Submit
64. When preparing to administer a drug dose to a client, the nurse examines the drug label. The nurse understands that the Food, Drug, and Cosmetic Act requires that drug labels state the:

Explanation

RATIONALE: A drug label must list the active ingredients and their quantities and proportions, as well as directions for use, a description of the package contents, and certain other information. The law doesn't require that the label include any other information.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Aschenbrenner, D.S., and Venable, S.J. Drug Therapy in Nursing, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2006, p. 18.

Submit
65. A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen (Tylenol) poisoning. The nurse administers acetylcysteine (Mucomyst) every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy?

Explanation

RATIONALE: Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Abrams, A.C., et al. Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed. Lippincott Williams & Wilkins, 2007, p. 123.

Submit
66. A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. Her physician orders neomycin (Neo-Tabs), 4 g by mouth daily in four divided doses. Her husband asks how neomycin decreases his wife's serum ammonia concentration. How should the nurse respond?

Explanation

RATIONALE: Neomycin lowers the blood ammonia level by reducing the quantity of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When present, these bacteria convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 101.

Submit
67. Which type of solution, when administered I.V., would cause fluid to shift from body tissues to the bloodstream?

Explanation

RATIONALE: A hypertonic solution causes the bloodstream to absorb fluids until pressure on both sides of the blood vessel is equal. A hypotonic solution causes fluids to move from the bloodstream into the tissues. An isotonic solution has no effect on the cell. Depending on the concentration of sodium, a sodium chloride solution can be isotonic, hypertonic, or hypotonic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1678.

Submit
68. A nurse is preparing to administer a blood transfusion. Which action should the nurse take first?

Explanation

RATIONALE: The nurse should first arrange for typing and crossmatching of the client's blood to ensure compatibility with donor blood. Comparing the identification wristband with the tag on the blood, starting an I.V. infusion of normal saline solution, and measuring the client's vital signs, although appropriate when preparing to administer a blood transfusion, come later in the procedure.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1737.

Submit
69. A cardiologist orders digoxin (Lanoxin) 0.125 mg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablets should the nurse administer in each dose? Record your answer using one decimal place. Answer: ___ tablets

Explanation

RATIONALE: The following formula
Dose on hand/Quantity on hand = Dose desired/X is used to calculate drug dosages:
The nurse should use the following equations:
0.25 mg/1 tablet = 0.125mg/X tablet; 0.25X = 0.125; divide both sides by 0.25; X = 0.5 tablet.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

Submit
70. A client is ordered heparin 6,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/ml. How many milliliters of heparin should the nurse administer? Record your answer using one decimal place. Answer: ___ milliliters

Explanation

RATIONALE: The following formula is used to calculate drug dosages: Dose on hand/Quantity on hand = Dose desired/X

The dose dispensed by the pharmacy is 10,000 units/1 ml and the desired dose is 6,000 ml. The nurse should use the following equations:

10,000 units/1 ml = 6,000 units/1 ml;

10,000X = 6,000 ml;

6,000 ml/10,000 ml = 0.6 ml

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

Submit
71. A client admitted to the hospital with diabetic ketoacidosis is receiving a continuous infusion of regular insulin. The physician orders an I.V. containing 1 liter of dextrose 5% in water at 150 ml/hour to be started when the client's blood glucose level reaches 250 mg/dl. The drip factor of the I.V. tubing is 15 gtt/ml. What is the drip rate for this I.V. infusion in drops per minute? Record your answer using one decimal place. Answer: ___ gtt/minute

Explanation

RATIONALE:
Drip rate = 150 ml ÷ 60 minutes × 15 gtt ÷ 1 ml
2,250 gtt ÷ 60 minutes = 37.5 gtt/minute

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

Submit
72. What is the first action that a nurse should take after omitting an ordered medication?

Explanation

RATIONALE: A nurse who has omitted an ordered medication should first notify the prescriber. She should then document the omission and the reason it occurred in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give the client an extra dose at the next scheduled administration time because doing so could cause adverse reactions or toxicity.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 811.

Submit
73. A client returns to his room from the postanesthesia care unit after undergoing right hemicolectomy. The physician orders 1 L of dextrose 5% in half-normal saline solution to infuse at 125 ml/hour. The drip factor of the available I.V. tubing is 15 gtt/ml. What's the drip rate in drops per minute? Round your answer to the nearest whole number. Answer: ___ gtt/minute

Explanation

RATIONALE: The flow rate is 125 ml/hour or 125 ml/60 minutes. Use the following equation:
Drip rate = 125 ml/60 minutes × 15 gtt/1 ml.
The drip rate is 31.25 gtt/minute (31 gtt/minute).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

Submit
74. A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000/μl. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order?

Explanation

RATIONALE: A client with a platelet count of 22,000/μl bleeds easily. The nurse should avoid using the I.M. route because the area is highly vascular. The client may bleed readily when penetrated by a needle, and it may be difficult for the nurse to stop the bleeding. The client's existing I.V. access would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subQ routes are preferred over I.M., but they're less effective for acute pain management than I.V.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1076.

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75. A nurse is monitoring the effectiveness of a client's drug therapy. When should the nurse obtain a blood sample to measure the trough drug level?

Explanation

RATIONALE: Measuring the blood drug concentration helps the nurse determine whether the dosing has achieved the therapeutic goal. To measure the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 711.

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76. A physician orders heparin 25,000 units in 250 ml of normal saline solution to infuse at 600 units/hour for a client who suffered an acute myocardial infarction. After 6 hours of heparin therapy, the client's partial thromboplastin time is subtherapeutic. The physician orders an increase in the infusion to 800 units/hour. The nurse should set the infusion pump to deliver how many milliliters per hour? Record your answer using a whole number. Answer: ___ milliliters/hour

Explanation

RATIONALE: The following formula is used to calculate drug dosages:
Dose on hand/Quantity on hand = Dose desired/X
The nurse should use the following equations:
25,000 units/250 ml = 800 units/hour/X.
Cross-multiply to solve for X and divide each side of the equation by 25,000 units
X = 8 ml/hour.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 5

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77. A client is to receive a glycerin suppository. When administering the suppository, the nurse should insert it approximately how far into the client's rectum?

Explanation

RATIONALE: The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. In an adult, this distance is approximately 4″.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 808.

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78. To give a Z-track injection, a nurse measures the correct medication dose and then changes the needle on the syringe. What is the rationale for this action?

Explanation

RATIONALE: Changing the needle decreases pain by eliminating any medication that may have been left on the needle and that could irritate the skin. Changing the needle has no bearing on whether the drug enters a blood vessel. Changing the needle isn't necessary to ensure that the client receives the entire dose and doesn't prevent the drug from flowing back into the needle track.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 589.

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79. A physician orders normal saline solution to infuse at a rate of 150 ml/hour for a client admitted with dehydration and pneumonia. How many liters of solution will the client receive during an 8-hour shift? Record your answer using one decimal place. Answer: ___ liters

Explanation

RATIONALE: The client is to receive the solution at an infusion rate of 150 ml/hour. 150 ml × 8 hours = 1,200 ml, the total volume in milliliters the client will receive during an 8-hour shift. Next, convert milliliters to liters by dividing by 1,000. The total volume in liters of normal saline solution that the client will receive in 8 hours is 1.2 L.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

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80. A nurse is calculating the proper dosage of medication for a child. What parameter should influence this calculation?

Explanation

RATIONALE: Body surface area in relation to weight is the most reliable method for estimating proper medication dosage for a child. Body surface area is more accurate for dosage calculation than height or weight alone because height and weight vary widely. Developmental stage doesn't enter into dosage calculation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams Wilkins, 2008, p. 58.

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81. A client is admitted to the hospital with lower GI bleeding. His hemoglobin level on admission to the emergency department is 7.3 g/dl. The physician orders 2 units of packed red blood cells (RBCs) to infuse over 1 hour each. The blood administration set has a drip factor of 10 gtt/ml. What is the flow rate in drops per minute? Round your answer to the nearest whole number. Answer: ___ gtt/minute

Explanation

RATIONALE: Each unit of packed RBCs contains 250 ml. Each unit is to infuse over 1 hour (60 minutes).
Use the following equation:
250 ml/60 minutes = 4.16 ml.
Multiply by the drip factor:
4.16 ml × 10 gtt = 41.6 gtt/minute (42 gtt/minute).

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Karch, A.M. Focus on Nursing Pharmacology, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 57.

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82. After suffering an acute myocardial infarction (MI), a client with a history of type 1 diabetes is ordered metoprolol (Lopressor) I.V. Which nursing interventions are associated with I.V. metoprolol administration? Select all that apply.

Explanation

RATIONALE: Metoprolol masks the common signs of hypoglycemia; therefore, the nurse should monitor glucose level closely in clients with diabetes. The nurse should monitor the client for the development of heart block or bradycardia. When used to treat an MI, metoprolol is contraindicated in clients with heart rates less than 45 beats/minute and any degree of heart block. The nurse should also monitor blood pressure frequently; metoprolol masks common signs and symptoms of shock, such as decreased blood pressure. The nurse should give the drug undiluted by direct injection. Although mixing with other drugs should be avoided, studies have shown metoprolol is compatible when mixed with meperidine hydrochloride or morphine sulfate, or when administered with alteplase infusion at a Y-site connection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 848.

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83. A nurse is preparing a teaching plan for a client who was ordered enalapril maleate (Vasotec) for treatment of hypertension. Which points should the nurse include in the teaching plan? Select all that apply.

Explanation

RATIONALE: When teaching the client about enalapril maleate, the nurse should tell him to avoid salt substitutions because these products may contain potassium that can cause light-headedness and syncope. Facial swelling or difficulty breathing should be reported immediately; the drug may cause angioedema, which would require discontinuation of the drug. The client should also be advised to change position slowly to minimize orthostatic hypotension. The nurse should tell the client to report light-headedness, especially in the first few days of therapy, so dosage adjustments can be made. The client should report signs of infection, such as sore throat and fever, because the drug may decrease white blood cell (WBC) count. WBC and differential counts should be performed before treatment, every 2 weeks for 3 months, and periodically thereafter.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 483.

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84. After sustaining a closed head injury, a client is ordered phenytoin (Dilantin) 100 mg I.V. every 8 hours for seizure prophylaxis. Which nursing interventions are necessary when administering phenytoin? Select all that apply.

Explanation

RATIONALE: If using I.V. bolus, the nurse should administer phenytoin by slow (50 mg/minute) I.V. push; too rapid an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when administering phenytoin I.V. Early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later, hypotension, arrhythmias, respiratory depression, and coma may occur. Death is caused by respiratory and circulatory depression. Phenytoin shouldn't be administered by I.V. push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. The nurse should mix I.V. doses in normal saline solution and use them within 30 minutes; mixtures with D5W will precipitate. Use of an in-line filter is recommended.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Springhouse Nurse's Drug Guide 2007. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1020.

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85. Which detail of a client's drug therapy is a nurse legally required to document?

Explanation

RATIONALE: The nurse is legally required to document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 251.

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