Exam 1

Question 1

In what type of injection should the Z-track method be utilized?

Answer 1

intramuscular

Question 2

What is the rationale for usage of the Z-track method in intramuscular injections?

Answer 2

the zigzag path seals the needle track, preventing the contents of the injection escaping the muscle tissue

Question 3

What layers of tissue should be displaced during intramuscular injection administration (Z-track)?

Answer 3

skin and subcutaneous tissue

Question 4

If the nurse experiences a problem reading a provider’s medication order, what would be an appropriate action for the nurse to take?

Answer 4

call the provider to verify order

Question 5

What are the rights of medication administration?

Answer 5

-right medication
-right dose
-right client
-right route
-right time
-right documentation

Question 6

Should the nurse document medication before or after giving it to a client?

Answer 6

after

Question 7

What is the most desired route of administration? What is the rationale?

Answer 7

oral, as it is the least invasive

Question 8

What is an important safety consideration for the nurse while administering topical medication?

Answer 8

using gloves to prevent absorption into nurse’s skin

Question 9

What should be considered when applying a topical patch to a patient?

Answer 9

rotation of sites as well as removing previous patches to prevent over medicating

Question 10

Nasal drops are to sterile as nasal spray is to ______.

Answer 10

clean

Question 11

What should be done to nasal spray after each use?

Answer 11

tip should be cleaned

Question 12

If a patient must receive more than 1 type of eye drop, how much time must elapse before the second type of medicated drop can be used?

Answer 12

5 mins to allow for absorption of first drops

Question 13

What would be a contraindication for using ear drops?

Answer 13

ruptured or perforated tympanic membrane

Question 14

How must medication utilized in rectal instillation be stored?

Answer 14

refrigeration or suppository will melt

Question 15

What device can be used for individuals experiencing difficulty coordinating actions while using a inhaler?

Answer 15

spacer

Question 16

For open wounds, what type of irrigation solution must be used?

Answer 16

sterile water

Question 17

For medication stored in a glass ampule, what measure must be taken to ensure safety?

Answer 17

aspirate medication into syringe using a filter straw/needle to avoid glass in injection

Question 18

Where are common sites for subcutaneous injections?

Answer 18

belly and back of arms

Question 19

What type of injection can be given with a 45-90 degree angle depending on patient adipose?

Answer 19

subcutaneous

Question 20

What angle should a intramuscular injection be given?

Answer 20

90 degrees

Question 21

What angle would be effective for an intradermal injection?

Answer 21

15 degrees

Question 22

What would indicate a successful administration of an intradermal injection?

Answer 22

presence of bleb or wheal

Question 23

Name 3 sites utilized for intramuscular medication injections:

Answer 23

deltoid, ventrogluteal and vastus lateralis

Question 24

What type of tubing is often used for decompression (removal of gastric contents)?

Answer 24

NG (nasogastric) tube

Question 25

What type of enteral tube is placed directly into the stomach?

Answer 25

Percutaneous endoscopic gastrostomy tube (PEG)

Question 26

What type of enteral tube is placed directly into the small intestine?

Answer 26

Percutaneous endoscopic jejunostomy tube (PEJ)

Question 27

What is a benefit of feeding via PEJ tubes?

Answer 27

nutrition is given past pyloric sphincter, reducing risk for aspiration, given the feeding doesn't reflux into stomach

Question 28

What must be used to flush enteral feeding tubes for immunocompromised or critically ill patients?

Answer 28

sterile water

Question 29

How must meds be given through an enteral tube?

Answer 29

SEPERATELY, and then followed by 15-30 ML of water between

Question 30

What action must be taken prior to giving medication through an enteral tube?

Answer 30

flush the tube with 15 mL of water with a 60 mL syringe

Question 31

What are of special importance in clients with impaired cognition to decrease the risk for aspiration during gastric feeding?

Answer 31

gastric residual checks

Question 32

How can a nurse minimize gastric cramping in intermittent or bolus feeding?

Answer 32

ensure formula is at room temperature

Question 33

How long should a client remain sitting up after bolus feeding?

Answer 33

1 hr

Question 34

What type of order refers to that which is given until prescriber changes it?

Answer 34

standing

Question 35

What type of order is given for a specific reason at a specific time?

Answer 35

single/ one-time

Question 36

What type of order is for a single time and must be given within 90 mins?

Answer 36

Now order

Question 37

What type of order is given when patient requires it?

Answer 37

PRN

Question 38

What type of order must be acted upon immediately?

Answer 38

STAT

Question 39

What type of order is for medication given outside of hospital?

Answer 39

prescriptions

Question 40

What is the anatomical landmark for intramuscular injections given in the deltoid?

Answer 40

acromion process

Question 40

With which type of medication administration must another personnel be present as a witness due to its vulnerable nature?

Answer 40

vaginal instillation

Question 41

What is priority in MRI safety?

Answer 41

patient must remove all metal

Question 42

Which urine specimen collection evaluates C and S? What is C & S?

Answer 42

clean catch/ "mid-stream" culture (what is it?) and sensitivity (how can it be killed?)

Question 43

What are some priorities of client education for a clean catch/"mid stream" urine specimen collection?

Answer 43

use palm to hold lid; don't touch inside. do not allow to container to touch the perineal area/skin.

Question 44

When is a first morning/ 8-hour urine specimen likely used?

Answer 44

pregnancy test hCG

Question 45

What action must a nurse take with urine specimens before taking them to the lab?

Answer 45

place the samples in a biohazard bag

Question 46

What is the greatest risk for CAUTI?

Answer 46

prolonged used of the urinary catheter, so they should be removed as soon as possible

Question 47

What may be an appropriate action for acute urinary retention caused by nerve injury?

Answer 47

utilization of catheter

Question 48

What must a client do before a 24 hour urine start time can begin?

Answer 48

void/empty bladder

Question 49

What range is a reliable indicator of stomach placement enteral feedings?

Answer 49

pH of 0-4

Question 50

How far should a catheter be inserted for females?

Answer 50

1-2 inches more than when urine is obtained

Question 51

How far should a catheter be inserted in males?

Answer 51

to the Y bifurcation of the catheter

Question 52

What should be used to inflate the balloon once the catheter is in place?

Answer 52

Sterile water

Question 53

What should a catheter drainage bag NOT be placed on?

Answer 53

Movable part of the bed

Question 54

How should a 24 hr urine specimen container be stored?

Answer 54

continually on ice

Question 55

What is the purpose of a capillary blood glucose?

Answer 55

To determine or monitor blood glucose levels of clients at risk for hyperglycemia or hypoglycemia

Question 56

What is the purpose of a 24 hr urine specimen collection?

Answer 56

measure the components of urine and is used to assess renal function

Question 57

What type of insulins should not be mixed with other types of insulins?

Answer 57

(Lantus) or insulin detemir (Levemir)

Question 58

What is NPH?

Answer 58

neutral protamine Hagedorn

Question 59

Why is it important to check for gastric residual volume before feedings in intermittent feedings?

Answer 59

because volume greater than 10 mL may indicate displacement of tubing

Question 60

What are some indications for feeding tube placement?

Answer 60

anorexia nervosa, CVA

Question 61

True or False: Patient must discontinue all meds during a 24hr urine specimen collection.

Answer 61

False