Science Medicine Pediatrics
NCLEX PN Fundamentals
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Correct answer: A. Administers the medication in small amounts at the back of the
cheek using a syringe.
The correct procedure for administering oral liquid medication to an infant is to
place small amounts of the medication at the back of the cheek, allowing time for the
infant to swallow each amount. This technique decreases the risk of choking and
ensures that all the medication is consumed.
The nurse reinforces teaching to a parent
[Incorrect answer B: Allows the client to sip the medication from a cup.] Although
of a 2 month old client regarding
cup feeding may be a method used for infants in specific cases, medication
administration of an oral liquid medication.
administration requires a more accurate measurement. A syringe can provide an
The nurse knows that the parent
accurate measurement and decrease the risk of waste due to the infants spitting or
understands the teaching when the parent
drooling.
performs which action.
[Incorrect answer C: Expels the medication from the dropper onto the back of the
A. Administers the medication in small
tongue.] Infants have an extrusion reflex (outward extension of tongue when it is
amounts at the back of the cheek using a
touched) and a decreased gag reflex. Dispensing medication onto the back of the
syringe.
tongue would increase the risk for aspiration.
B. Allows the client to sip the medication
from a cup.
[Incorrect answer D: Mixes the medication in the infants bottle of formula.] It is
C. Expels the medication from a dropper
very important for the infant to receive the entire dose of the medication. Medication
onto the back of the tongue.
should never be mixed in a bottle or formula as the infant may not consume the
D Mixes the medication in the infants bottle
entire amount.
of formula.
Educational Objective: Using a syringe to measure medication for an infant is the
most accurate technique to ensure that the proper amount is being administered. The
extrusion reflex and a decreased gag reflex in infants age <4 months increase the risk
of choking and aspiration. Using a syringe to instill the medication at the back of the
cheek decreases the risk of choking and ensures that the correct amount is
consumed
, Correct answer: A. Check the health care provider's prescription in the medical
record.
Safe medication administration is conducted according to 6 rights.
- Right client using 2 identifiers
- Right medication
- Right dose
- Right route
- Right time
- Right documentation
The nurse is administering a pink pill to a
When a mentally competent client questions a drug administration, the safest option
hospitalized medical-surgical client. The
is to first check the prescription to verify the 6 rights of medication administration. If
alert, oriented client says, “This is a pill I
an error is ruled out (eg, different brand, new order) the nurse should follow up with
haven’t seen before.” What follow-up
appropriate teaching.
action should the nurse take next?
Incorrect Answers:
A. Check the health care provider’s
[B: Explain that the health care provider has prescribed the medication.] The nurse
prescription in the medical record.
must first verify all aspects of proper medication administration. If they are correct,
B. Explain that the health care provider has
the nurse should provide appropriate teaching on why the health care provider
prescribed the medication.
prescribed the medication. Explaining that the nurse is just following orders is rarely
C. Look up the medication in the
the correct answer.
pharmacology reference.
D. Teach the client about the purpose of
[C: Look up the medication in the pharmacology reference.] A pharmacology
the medication.
reference can verify information about the medication but will not confirm that the
client is the correct recipient. Acceptable identifiers include first and last name,
medical record number, and birth date.
[D: Teach the client about the purpose of the medication.] The nurse can teach the
client about the purpose of the medication after the 6 rights have been verified.
Educational Objective:
When a competent client questions a new medication, the nurse should first try to
verify the 6 rights of safe medication administration: right client, medication, dose,
route, time, and documentation. If safe administration has been confirmed, the nurse
should then provide appropriate teaching to the client.
, Correct Answer: B and C
A glass ampule is a single-dose medication container with a scored area on the neck
that must be broken to withdraw the medication. When preparing medication from a
glass ampule, the nurse ensures safety and prevents contamination during
medication administration by:
- Flicking the upper stem of the ampule with a fingernail several removal of
medication from the ampule neck.
- Using sterile gauze to break the ampule neck away from the nurse's body to
The nurse is preparing an injection of IM prevent injury from glass shards.
haloperidol from a glass ampule. Which of - Setting the ampule on a flat surface or inverting to withdraw the medication.
the following actions by the nurse are - Disposing of the ampule in a sharps container.
appropriate? Select all that apply.
[Incorrect Answer: A. Attaches an 18-gauge injection needle to a syringe for
A. Attaches an 18-gauge injection needle to withdrawal of medication.] Glass shards may be present in the medication after an
a syringe for withdrawal of medication. ampule is opened. To prevent the accidental administration of glass shards, the nurse
B. Breaks the ampule neck away from the must use a filter needle, rather than an injection needle, when withdrawing
nurse's body to prevent injury from glass. medication.
C. Disposes of the empty glass ampule in
sharps container. [Incorrect Answer: D. Injects air into the glass ampule prior to withdrawing the
D. Injects air into the glass ampule prior to medication.] Unlike when withdrawing medication from a vial, air should not be
withdrawing the medication. injected into a glass ampule; this causes the contents to spill from the container.
E. Rests and steadies the needle on the
ampules outer rim to withdraw mediation. [Incorrect Answer: E. Rests and steadies the needle on the ampule's outer rim to
withdraw medication.] Ensure that the filter needle does not touch the glass edges,
which are not sterile, as this can introduce bacteria.
Education Objective:
When preparing medication from a glass ampule, the nurse breaks the ampule away
from the body and discards it in the sharps container. The nurse withdraws the
medication using a filter needle to prevent the injection of glass shards, avoids
touching the needle to the contaminated ampule edges, and avoids injecting air to
prevent spillage.
, Correct Answer: B, C, D, and E
Pediatric administration of rectal suppositories is similar to the adult technique, with a
few key modifications due to the small size of a child's colon and varying
developmental needs. Age-appropriate explanations and/or distractions should be
implemented to reduce stress. Toddlers and infants may benefit from distraction with
a toy; preschoolers and older children can be instructed to take deep breaths or
count during the procedure.
Basic steps for suppository administration include the following:
The pediatric nurse is preparing to 1. Apply clean gloves and position the client appropriately based on age and size
administer an acetaminophen suppository (eg, infant supine with knees and feet raised, older child side-lying with knees bent)
to an 11-month-old with pyrexia. Which 2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based
actions are appropriate? Select all that products can reduce absorption.
apply. 3. Inserts the suppository past the internal sphincter using the fifth finger if the child
is under 3 years. Use of the index finger may cause injury to the colon or sphincters
A. Advance past the external sphincter in children younger than age 3 years.
only. 4. Angle suppository and guide it along the rectal wall. The suppository should
B. Guide suppository along the rectal wall. remain in contact with the rectal mucosa (and not be buried inside stool) to ensure
C. Hold buttocks together firmly after systemic absorption.
insertion. 5. Hold the buttocks together for several minutes, or until the urge to defecate has
D. Position client supine with knees and passed, to prevent immediate expulsion.
feet raised. 6. If a bowel movement occurs with 10-30 minutes, observe for the presence of the
E. Use gloved fifth finger for insertion. suppository.
[Incorrect Answer: A. Advance past the external sphincter only.] The suppository
must be inserted past both the external and internal sphincters for proper
placement. If not inserted far enough, it may be expelled before achieving a
therapeutic effect.
Educational Objective:
In children younger than age 3 years, suppositories are inserted with the fifth finger
of the nurse's gloved hand. Age-appropriate explanations and/or distractions are
implemented to reduce distress
See an expert-written answer!
NCLEX PN Fundamentals
Save
Students also studied
Flashcard sets Study guides Practice tests
Unit 3 test study guide Class 5: Cardiovascular disorders Bio of Movement reflection assessm... Vital sig
45 terms 49 terms 10 terms 26 terms
Carolina_Tamayo6 Preview jenna_may853 Preview klinker81 Preview em
Correct answer: A. Administers the medication in small amounts at the back of the
cheek using a syringe.
The correct procedure for administering oral liquid medication to an infant is to
place small amounts of the medication at the back of the cheek, allowing time for the
infant to swallow each amount. This technique decreases the risk of choking and
ensures that all the medication is consumed.
The nurse reinforces teaching to a parent
[Incorrect answer B: Allows the client to sip the medication from a cup.] Although
of a 2 month old client regarding
cup feeding may be a method used for infants in specific cases, medication
administration of an oral liquid medication.
administration requires a more accurate measurement. A syringe can provide an
The nurse knows that the parent
accurate measurement and decrease the risk of waste due to the infants spitting or
understands the teaching when the parent
drooling.
performs which action.
[Incorrect answer C: Expels the medication from the dropper onto the back of the
A. Administers the medication in small
tongue.] Infants have an extrusion reflex (outward extension of tongue when it is
amounts at the back of the cheek using a
touched) and a decreased gag reflex. Dispensing medication onto the back of the
syringe.
tongue would increase the risk for aspiration.
B. Allows the client to sip the medication
from a cup.
[Incorrect answer D: Mixes the medication in the infants bottle of formula.] It is
C. Expels the medication from a dropper
very important for the infant to receive the entire dose of the medication. Medication
onto the back of the tongue.
should never be mixed in a bottle or formula as the infant may not consume the
D Mixes the medication in the infants bottle
entire amount.
of formula.
Educational Objective: Using a syringe to measure medication for an infant is the
most accurate technique to ensure that the proper amount is being administered. The
extrusion reflex and a decreased gag reflex in infants age <4 months increase the risk
of choking and aspiration. Using a syringe to instill the medication at the back of the
cheek decreases the risk of choking and ensures that the correct amount is
consumed
, Correct answer: A. Check the health care provider's prescription in the medical
record.
Safe medication administration is conducted according to 6 rights.
- Right client using 2 identifiers
- Right medication
- Right dose
- Right route
- Right time
- Right documentation
The nurse is administering a pink pill to a
When a mentally competent client questions a drug administration, the safest option
hospitalized medical-surgical client. The
is to first check the prescription to verify the 6 rights of medication administration. If
alert, oriented client says, “This is a pill I
an error is ruled out (eg, different brand, new order) the nurse should follow up with
haven’t seen before.” What follow-up
appropriate teaching.
action should the nurse take next?
Incorrect Answers:
A. Check the health care provider’s
[B: Explain that the health care provider has prescribed the medication.] The nurse
prescription in the medical record.
must first verify all aspects of proper medication administration. If they are correct,
B. Explain that the health care provider has
the nurse should provide appropriate teaching on why the health care provider
prescribed the medication.
prescribed the medication. Explaining that the nurse is just following orders is rarely
C. Look up the medication in the
the correct answer.
pharmacology reference.
D. Teach the client about the purpose of
[C: Look up the medication in the pharmacology reference.] A pharmacology
the medication.
reference can verify information about the medication but will not confirm that the
client is the correct recipient. Acceptable identifiers include first and last name,
medical record number, and birth date.
[D: Teach the client about the purpose of the medication.] The nurse can teach the
client about the purpose of the medication after the 6 rights have been verified.
Educational Objective:
When a competent client questions a new medication, the nurse should first try to
verify the 6 rights of safe medication administration: right client, medication, dose,
route, time, and documentation. If safe administration has been confirmed, the nurse
should then provide appropriate teaching to the client.
, Correct Answer: B and C
A glass ampule is a single-dose medication container with a scored area on the neck
that must be broken to withdraw the medication. When preparing medication from a
glass ampule, the nurse ensures safety and prevents contamination during
medication administration by:
- Flicking the upper stem of the ampule with a fingernail several removal of
medication from the ampule neck.
- Using sterile gauze to break the ampule neck away from the nurse's body to
The nurse is preparing an injection of IM prevent injury from glass shards.
haloperidol from a glass ampule. Which of - Setting the ampule on a flat surface or inverting to withdraw the medication.
the following actions by the nurse are - Disposing of the ampule in a sharps container.
appropriate? Select all that apply.
[Incorrect Answer: A. Attaches an 18-gauge injection needle to a syringe for
A. Attaches an 18-gauge injection needle to withdrawal of medication.] Glass shards may be present in the medication after an
a syringe for withdrawal of medication. ampule is opened. To prevent the accidental administration of glass shards, the nurse
B. Breaks the ampule neck away from the must use a filter needle, rather than an injection needle, when withdrawing
nurse's body to prevent injury from glass. medication.
C. Disposes of the empty glass ampule in
sharps container. [Incorrect Answer: D. Injects air into the glass ampule prior to withdrawing the
D. Injects air into the glass ampule prior to medication.] Unlike when withdrawing medication from a vial, air should not be
withdrawing the medication. injected into a glass ampule; this causes the contents to spill from the container.
E. Rests and steadies the needle on the
ampules outer rim to withdraw mediation. [Incorrect Answer: E. Rests and steadies the needle on the ampule's outer rim to
withdraw medication.] Ensure that the filter needle does not touch the glass edges,
which are not sterile, as this can introduce bacteria.
Education Objective:
When preparing medication from a glass ampule, the nurse breaks the ampule away
from the body and discards it in the sharps container. The nurse withdraws the
medication using a filter needle to prevent the injection of glass shards, avoids
touching the needle to the contaminated ampule edges, and avoids injecting air to
prevent spillage.
, Correct Answer: B, C, D, and E
Pediatric administration of rectal suppositories is similar to the adult technique, with a
few key modifications due to the small size of a child's colon and varying
developmental needs. Age-appropriate explanations and/or distractions should be
implemented to reduce stress. Toddlers and infants may benefit from distraction with
a toy; preschoolers and older children can be instructed to take deep breaths or
count during the procedure.
Basic steps for suppository administration include the following:
The pediatric nurse is preparing to 1. Apply clean gloves and position the client appropriately based on age and size
administer an acetaminophen suppository (eg, infant supine with knees and feet raised, older child side-lying with knees bent)
to an 11-month-old with pyrexia. Which 2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based
actions are appropriate? Select all that products can reduce absorption.
apply. 3. Inserts the suppository past the internal sphincter using the fifth finger if the child
is under 3 years. Use of the index finger may cause injury to the colon or sphincters
A. Advance past the external sphincter in children younger than age 3 years.
only. 4. Angle suppository and guide it along the rectal wall. The suppository should
B. Guide suppository along the rectal wall. remain in contact with the rectal mucosa (and not be buried inside stool) to ensure
C. Hold buttocks together firmly after systemic absorption.
insertion. 5. Hold the buttocks together for several minutes, or until the urge to defecate has
D. Position client supine with knees and passed, to prevent immediate expulsion.
feet raised. 6. If a bowel movement occurs with 10-30 minutes, observe for the presence of the
E. Use gloved fifth finger for insertion. suppository.
[Incorrect Answer: A. Advance past the external sphincter only.] The suppository
must be inserted past both the external and internal sphincters for proper
placement. If not inserted far enough, it may be expelled before achieving a
therapeutic effect.
Educational Objective:
In children younger than age 3 years, suppositories are inserted with the fifth finger
of the nurse's gloved hand. Age-appropriate explanations and/or distractions are
implemented to reduce distress
See an expert-written answer!
