Basic Pharmacology For Nurses 17Th Ed By Clayton -Test Bank

Chapter 03: Drug Action Across the Life Span Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition MULTIPLE CHOICE 1. What time will the trough blood level need to be drawn if the nurse administers the intravenous medication dose at 9:00 AM? a. 6:30 AM b. 8:30 AM c. 9:30 AM d. 11:30 AM ANS: B Trough blood levels measure the lowest blood level of medicine and are obtained just before the dose is administered. In this case, 6:30 AM is too early to obtain the blood level. The other two times occur after the medication is administered. DIF: Cognitive Level: Application REF: Page 27 OBJ: 2 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 2. What will the nurse expect the health care provider’s order to be when starting an older adult patient on thyroid hormone replacement therapy? a. Administering a loading dose of the drug b. Directions on how to taper the drug c. A dosage that is one third to one half of the regular dosage d. A dosage that is double the regular dosage ANS: C To prevent toxicity, dosages for new medications in older adults should be one third to one half the amount of a standard adult dosage. Loading doses of drugs could cause severe toxicity. Tapering off is characteristic of discontinuation of medications and is not appropriate for this situation. Older adults generally need a lower medication dosage than younger patients. DIF: Cognitive Level: Application REF: Page 29 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 3. Which drugs cause birth defects? a. Teratogens b. Carcinogens c. Metabolites d. Placebos ANS: A Teratogens are drugs that cause birth defects. Carcinogens cause cancer. Metabolites are the end product of metabolism. Placebos are drugs that have no pharmacologic activity. DIF: Cognitive Level: Knowledge REF: Page 30 OBJ: 6 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 4. Which life-threatening illness may occur as a result of aspirin (salicylate) administration during viral illness to patients younger than 20 years of age? a. Anaphylactic shock b. Reye’s syndrome c. Chickenpox d. Influenza A ANS: B Children are susceptible to Reye’s syndrome if they ingest aspirin at the time of or shortly after a viral infection of chickenpox or influenza. Anaphylactic shock is caused by a hypersensitivity reaction. Chickenpox is the result of being infected with a virus. Influenza A is caused by a pathogen. DIF: Cognitive Level: Knowledge REF: Page 29 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 5. Which classification of medications commonly causes allergic reactions in children? a. Antacids b. Analgesics c. Antibiotics d. Anticonvulsants ANS: C Antibiotics, especially penicillins, commonly cause allergic reactions in children. Intravenous antibiotics can cause rapid reactions; therefore, the pediatric patient’s response to a medication should be assessed and monitored closely. Antacids rarely cause allergic reactions. Children are not particularly allergic to analgesics or anticonvulsants. DIF: Cognitive Level: Knowledge REF: Page 29 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety: Patient Education; Development 6. After giving instructions to an expectant mother about taking medications during pregnancy, which patient statement indicates the need for further teaching? a. “I will not take herbal medicines during pregnancy.” b. “For morning sickness, I will try crackers instead of taking a drug.” c. “If I get a cold, I will avoid taking nonprescription medications until I check with my physician.” d. “I will limit my alcohol intake to only one glass of wine weekly.” ANS: D Alcohol needs to be eliminated during pregnancy and for 2 to 3 months prior to conception. Limited studies are available regarding the use of herbal medications in general, and thus they should be avoided during pregnancy. Alternative nonpharmacologic treatments are appropriate to use during morning sickness. The pregnant woman should also avoid using nonprescription drugs because few data are available about safe use in pregnancy. Because few medicines can be considered completely safe for use in pregnancy, the physician needs to approve and recommend the use of nonprescription drugs. DIF: Cognitive Level: Application REF: Page 31 | Page 32 OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education 7. When is the ideal time for a nursing mother to take her own medications? a. Before the infant latches on to begin to breastfeed b. As soon as the mother wakes up in the morning c. Right before the mother goes to sleep at night d. As soon as the infant finishes breastfeeding ANS: D Taking medications after breastfeeding reduces the amount of the medication that will reach the baby. Medications taken directly before breastfeeding may have a high concentration in the milk and possibly pass on to the baby. The mother must take into consideration when her medications are ordered to be taken and schedule them around breastfeeding. DIF: Cognitive Level: Comprehension REF: Page 32 OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education 8. Which age-related change would affect transdermal drug absorption in geriatric patients the most? a. Difficulty swallowing b. Diminished kidney function c. Changes in pigmentation d. Altered circulatory status ANS: D The decreased circulation that occurs with aging will affect transdermal drug absorption. Difficulty swallowing would not affect transdermal drugs being absorbed. Kidney function affects drug excretion. Changes in pigmentation would not affect transdermal drug absorption. DIF: Cognitive Level: Application REF: Page 23 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 9. Which intervention would be considered to reduce accumulation of a drug in a patient who has decreased liver function? a. Decreasing the time interval between dosages b. Reducing the dosage c. Administering the medication intravenously d. Changing the drug to one that has a longer half-life ANS: B Dosages must be reduced to prevent accumulation. Decreasing the time interval between dosages would increase the accumulation of the drug. The intravenous route has the fastest absorption and with liver dysfunction would increase the accumulation of the drug. A similar drug with a longer half-life would stay in the system longer; with impaired liver function, the result would be increased accumulation. DIF: Cognitive Level: Comprehension REF: Page 24 | Page 25 OBJ: 2 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion 10. The nurse is teaching an elderly patient with difficulty swallowing about his medications. Which explanation by the nurse is most helpful? a. “Enteric coated tablets can be crushed and taken with applesauce.” b. “Tablets that are scored can be broken in half.” c. “Medications labeled ‘SR’ can be crushed.” d. “Avoid taking medications in liquid form.” ANS: B It is acceptable to break scored tablets in half to facilitate swallowing of the medication. Enteric coated tables should never be crushed because of the effect on the absorption rate and potential for toxicity. Medications labeled “SR” indicate “sustained release” and should not be crushed because of the effect on the absorption rate. Medication in liquid form may be easier to swallow. DIF: Cognitive Level: Application REF: Page 30 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education 11. The nurse is administering an antibiotic intravenously. Which blood level determines the lowest amount of medication present in the patient? a. Peak b. Serum c. Therapeutic d. Trough ANS: D The lowest amount of a medication in the blood is the trough. The peak is the highest amount of medication in the blood. Serum level identifies the amount of medication present. Therapeutic levels identify the range in which a medication is effective. DIF: Cognitive Level: Knowledge REF: Page 27 OBJ: 2 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 12. Which patient would the nurse identify as having the lowest rate of absorption of enteral medications? a. A 5-year-old boy b. An 18-year-old woman c. A 55-year-old man d. An 85-year-old woman ANS: A Males’ stomachs empty more rapidly; children have increased motility, resulting in decreased absorption time. As one gets older, gastrointestinal (GI) motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption. Males’ stomachs empty more rapidly; however, as one gets older, GI motility is decreased, resulting in an increase in absorption time. As one gets older, GI motility is decreased, allowing for increased absorption time; women have slower gastric emptying, resulting in more time for absorption. DIF: Cognitive Level: Application REF: Page 21 | Page 24 | Page 21 OBJ: 3 | 4 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development 13. What is the definition of cumulative effect of a drug? a. Drug toxicity related to overmedication b. Drug buildup related to decreased metabolism c. The inability to control the ingestion of drugs d. The need for higher dosage to produce the same effect as previous lower dosages ANS: B Cumulative effects are related to diminished metabolism or excretion of a drug that causes it to accumulate. Cumulative effects can lead to drug toxicity. Toxicity occurs when adverse effects are severe. Inability to control the ingestion of drugs is drug dependence. The need for higher dosage to produce the same effect as previous lower dosages is the definition of tolerance. DIF: Cognitive Level: Knowledge REF: Page 23 OBJ: 2 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 14. Which patient, when compared with the general population, would require a larger dose or more frequent administration of a drug to attain a therapeutic response? a. A 29-year-old who has been diagnosed with kidney failure b. A 35-year-old obese male who is being evaluated for an exercise program c. A 52-year-old diagnosed with hypothyroidism and decreased metabolic rate d. A 72-year-old with decreased circulatory status ANS: B An obese individual would require a larger dose of a drug to attain a therapeutic response. An individual with kidney failure would require less medication because of decreased excretory ability. Individuals with decreased metabolic rate would metabolize drugs more slowly and require smaller doses or less frequent administration. Individuals with decreased circulation would require less medication. DIF: Cognitive Level: Application REF: Page 21 | Page 22 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion 15. A resident in a long-term care facility reports difficulty swallowing enteric coated aspirin and asks the nurse to crush it prior to administration. The most appropriate action for the nurse to take is to a. crush the tablet and mix with applesauce. b. encourage the resident to swallow the tablet with a full glass of water. c. hold the medication and notify the physician. d. substitute a regular aspirin for the enteric coated tablet. ANS: C The medication should be held and the physician notified. The physician has the authority to determine how to proceed in this situation. Enteric coated tablets should not be crushed because this will increase the absorption rate and the potential for toxicity. Geriatric patients may have difficulty swallowing and are at risk for choking and aspiration. They should not be encouraged to swallow medications if they report difficulty swallowing. The physician must determine if a substitution can be ordered. Prescribing is not in the nurse’s scope of practice. DIF: Cognitive Level: Analysis REF: Page 23 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education MULTIPLE RESPONSE 1. One of the prescribed medications for a 36-week gestational age baby girl is a topical water soluble medication to be applied to the perineum daily to treat an inflammatory rash. What considerations is the nurse aware of before medication administration? (Select all that apply.) a. Age of the client b. Location of topical application c. Increased intestinal transit rate d. Condition of the skin e. Gastric pH of 8 ANS: A, B, D The premature infant’s outer layer of skin is not fully developed, although it is more hydrated, which will enhance the absorption of the topical water soluble medication. Neonates often wear diapers, which will act as an occlusive dressing, thereby increasing absorption. The client’s inflammatory condition will increase the absorption of medication. The intestinal transit rate increases as the newborn matures. This is irrelevant when a medication is applied topically. Gastric pH would not factor into metabolism of a medication that is applied topically. DIF: Cognitive Level: Application REF: Pages 21-22 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development 2. The nurse is caring for a 4-month-old child who is on a water soluble medication for seizures. The child’s mother voices concern that the dosage seems “too much” for the child’s age and would like the dosage verified. What actions will the nurse take? (Select all that apply.) a. Verify dosage requirements in the Physicians’ Desk Reference (PDR) in mg/kg. b. Compare the water composition requirements of adults and children. c. Evaluate lean body mass and total fat content in adults and infants. d. Chart “refused per mother” on the MAR and do not administer. e. Compare transportation in the circulation of plasma bound proteins between adults and children. ANS: A, B The PDR lists the recommended dosages for all age groups. Because dilution may vary among age groups, the water concentration should be verified prior to administration. As we age, lean body mass and total body water decrease while total fat content increases; however, this drug is not fat soluble. The nurse is responsible for administering the medication as ordered after verifying that it is correct; the mother is asking for verification, not refusal of administration. Drugs that are relatively insoluble are transported in the circulation by being bound to plasma proteins; however, this drug is water soluble. DIF: Cognitive Level: Application REF: Page 28 | Page 29 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 3. For which reason(s) is/are elderly patients at increased risk for drug interactions and toxicity? (Select all that apply.) a. They have a higher incidence of malnourishment. b. Their renal function is enhanced. c. They have increased use of multiple medications. d. Hepatic function is reduced. e. There are often issues with swallowing. ANS: A, C, D Older adult patients have an increased incidence of malnourishment, are often on multiple medications, and have reduced hepatic function, all of which put them at increased risk for drug interactions and toxicity. Renal function diminishes in the elderly as a result of decreased renal blood flow, reduced cardiac output, loss of glomeruli, and diminished tubular function and concentrating ability. Older adults have swallowing difficulties, leading to compliance issues, but taking drugs less often would not result in toxicity. DIF: Cognitive Level: Comprehension REF: Page 29 | Page 30 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Development 4. Which patient(s) require(s) special considerations for medication administration? (Select all that apply.) a. A 29-year-old pregnant woman b. A 2-month-old baby c. An 18-year-old college student d. A 45-year-old farmer e. An 82-year-old retired nurse ANS: A, B, E Drug therapy during pregnancy should be avoided. Recommendations by the provider are necessary during any stage of pregnancy. Pediatric and elderly patients are affected by differences in muscle mass and blood flow to muscles, as well as other physiological systems. Teenagers and adult patients do not typically require special considerations for medication administration. DIF: Cognitive Level: Application REF: Page 21 | Page 24 OBJ: 3 | 4 | 5 | 6 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development 5. Which factor(s) in a patient would influence GI absorption of medications? (Select all that apply.) a. Stomach pH b. Level of consciousness c. Fever d. Blood flow to gastric mucosa e. Weight f. Body surface area ANS: A, D Absorption by passive diffusion across the membranes depends on the pH of the environment. Increased blood flow to gastric mucosa increases absorption of medication and decreases time of absorption. Drug absorption does not depend on the mental status of the patient. Fever does not affect drug absorption. The patient’s absolute weight and body surface area do not affect drug absorption, although problems associated with weight greater than or less than normal may be a factor in the process. DIF: Cognitive Level: Application REF: Page 23 | Page 24 OBJ: 2 | 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 6. When receiving a report on a new admission from the emergency room, the nurse learns that the patient is newly diagnosed with renal failure. Which medication(s) in the patient’s medication history will require dosage adjustment by the physician? (Select all that apply.) a. Lithium b. Tobramycin c. Atenolol d. Quinidine e. Ampicillin ANS: A, B, C, D, E Lithium, tobramycin, atenolol, quinidine, and ampicillin are all select medications that require dosage adjustment in renal failure. DIF: Cognitive Level: Application REF: Page 27 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education 7. Prenatal education is being provided by the nurse at a maternal family child clinic. What information should be relayed? (Select all that apply.) a. Herbal medicines are considered safe. b. Limit tobacco consumption to less than two cigarettes per day. c. Encourage a folic acid supplement. d. One alcoholic beverage per day is acceptable in the last trimester. e. Encourage nonpharmacologic treatments for symptoms such as nausea. ANS: C, E Good nutrition with appropriate ingestion of vitamins (especially folic acid) is particularly important during pregnancy to prevent birth defects. Before using medicines, pregnant women should be encouraged to try nonpharmacologic treatments. Herbal medicines that have not been scientifically tested in women during pregnancy should be avoided. Advise against the use of tobacco. Mothers who smoke have a higher frequency of miscarriage, stillbirths, premature births, and low birth weight infants. Consumption of alcohol should be eliminated 2 to 3 months before planned conception, as well as during pregnancy. DIF: Cognitive Level: Application REF: Page 30 | Page 32 OBJ: 6 TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Health Promotion and Maintenance NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education Chapter 07: Percutaneous Administration Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition MULTIPLE CHOICE 1. A patient has an infected wound with large amounts of drainage. Which type of dressing would the nurse use? a. Telfa b. OpSite c. DuoDerm d. AlgiDERM ANS: D AlgiDERM is manufactured from seaweed and is recommended for infected wounds because it is an exudate absorber. Telfa and OpSite do not absorb exudates. DuoDerm is for light to moderate wound drainage. According to the manufacturer, it does absorb exudates, but it is best for wounds with moderate drainage. DIF: Cognitive Level: Comprehension REF: Page 83 OBJ: 1 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Tissue Integrity; Infection 2. Where would the nurse apply nitroglycerin ointment on a male patient? a. The same site that was previously used b. A hairy area of the chest c. The upper arm d. The back of the knee ANS: C Any area without hair may be used. Most people prefer the chest, flank, or upper arm areas. Sites should be rotated. The back of the knee is not suitable for applying medication because of the joint motion and difficulty of keeping a dressing in place. DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 3. Where will the nurse administer a medication that was ordered to be given sublingually? a. Between the molar teeth and cheek b. Below the skin surface c. Under the tongue d. Into the conjunctival sac ANS: C The sublingual area is underneath the tongue. Between the molar teeth and cheek is the buccal area. Medication administered below the skin surface is intradermal administration. The conjunctival sac is between the eyelids and eyeball. DIF: Cognitive Level: Knowledge REF: Page 88 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 4. Why are sublingual and buccal medications rapidly absorbed? a. Their action is localized to the mouth. b. They are metabolized in the liver. c. Blood flow is diminished in these sites. d. These drugs pass directly into systemic circulation. ANS: D Sublingual medications are rapidly absorbed into systemic circulation because of the increased blood flow to these areas and avoid the “first pass” effect of the liver where extensive metabolism usually takes place. These routes do not contain drug effects to the oral area and they bypass the liver. These sites are highly vascular. DIF: Cognitive Level: Comprehension REF: Page 88 OBJ: 5 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 5. Which medications must be sterile? a. Topical b. Vaginal c. Ophthalmic d. Nasal ANS: C Ophthalmic (eye) medications must be sterile. Topical, vaginal, and nasal applications do not need to be sterile. DIF: Cognitive Level: Knowledge REF: Page 89 OBJ: N/A TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 6. Which action will the nurse perform when doing a wet to dry dressing every 4 hours on a patient with a deep wound? a. Pack the wound tightly with gauze. b. Saturate the dressing with as much liquid as possible. c. Use Montgomery tapes or a binder to secure the dressing. d. Apply the new moist dressing over the existing one. ANS: C The use of Montgomery tapes or a binder reduces the irritation of nearby skin tissue. The dressing should be packed into the wound loosely. The dressings should be wrung out to prevent dripping. The previous dressing should always be completely removed. DIF: Cognitive Level: Application REF: Page 83 OBJ: 1 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 7. When applying nitroglycerin topically, which nursing intervention is correct? a. Secure the paper on two sides with tape. b. Shave the area prior to application of the paper. c. Wear gloves while placing the new paper. d. Remind the patient to discontinue use of the medication if chest pain is relieved. ANS: C Wearing gloves prevents accidental exposure to the medication. The area where the paper is placed should be covered with plastic wrap and taped into place to prevent medication from seeping out. Shaving may cause skin irritation. The dosage and frequency of application should be gradually reduced over 4 to 6 weeks, and the patient should contact the health care provider if adjustment is desired. DIF: Cognitive Level: Application REF: Page 86 | Page 87 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 8. Where does the nurse correctly administer ophthalmic medication? a. At the inner canthus of the eye b. In the lower conjunctival sac c. Directly onto the eyeball d. To the outer corner of the eyelid ANS: B The lower conjunctival sac is exposed by applying gentle traction to the lower lid at the bony rim of the orbit. The inner canthus allows medication to flow out of the eye. Applying directly to the eyeball risks injury to the globe. The outer corner of the eyelid allows medication to flow out of the eye. DIF: Cognitive Level: Knowledge REF: Page 89 OBJ: N/A TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 9. Which effect would be important for the nurse to address when teaching a patient about the overuse of nose drops? a. Rebound b. Ceiling c. Idiosyncratic d. Measured ANS: A Rebound effect may occur with overuse of some medications. Ceiling effect is the greatest attainable response. An idiosyncratic effect may occur even with prudent use of nose drops. Measured effect is the patient’s response to the medication. DIF: Cognitive Level: Application REF: Page 93 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion 10. Which nursing assessment accurately describes the results of an intradermal skin test? a. Itching and weeping b. Erythema and induration c. Swelling and coolness d. Pallor and drainage ANS: B The result should be measured by diameter of erythema in millimeters, and the induration should be palpated and measured in millimeters. Itching is not relevant to the results; weeping should be reported to the health care provider but is not pertinent to the evaluation of the skin test. Swelling, coolness, pallor, and drainage are not relevant to evaluation; reporting this to the health care provider is appropriate but not pertinent to the evaluation of the skin test. DIF: Cognitive Level: Comprehension REF: Pages 83-85 OBJ: 2 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment 11. The nurse is teaching a patient about nitroglycerin ointment. Which is an advantage of this form of the medication? a. It does not give the patient a bad taste in the mouth. b. The amount of ointment does not matter in obtaining a therapeutic response. c. It does not cause headaches as an adverse effect. d. It provides relief of anginal pain for several hours longer than sublingual medication. ANS: D Nitroglycerin ointment provides relief of anginal pain for several hours longer than sublingual preparations. Nitroglycerin pills do not have a bad taste. Dosage is critical to the success of use. All nitroglycerin preparations may cause headaches because of vasodilation. DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain; Health Promotion 12. A patient with metastatic cancer is being admitted for pain control. Which action will the nurse perform in administering a transdermal patch? a. After removal, dispose of the old patch in a receptacle in the patient’s room. b. Change the fentanyl patch every day, either in the morning or at bedtime. c. Hold the short-acting oral pain medication when a fentanyl patch is initiated. d. Label the patch with date, time, dosage, and initials after patch placement. ANS: D Labeling is appropriate when transdermal disks are placed. Patches are to be disposed of in a receptacle on the medication cart, not in the patient’s room. Fentanyl patches are changed every 72 hours. Fentanyl patches take up to 12 hours to be effective; therefore, short-acting pain medication is continued. DIF: Cognitive Level: Application REF: Page 87 OBJ: 4 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Pain; Safety 13. What is the rationale for the nurse applying gentle pressure to the inner corner of the eyelid after instilling eyedrops? a. Decreases the risk of infection b. Maintains intraocular pressure c. Prevents systemic effects d. Provides comfort to the patient ANS: C Application of pressure to the inner corner of the eye prevents the medication from entering the canal, where it would be absorbed in the vascular mucosa of the nose and produce systemic effects. Application of pressure to the inner corner of the eye does not decrease infection, maintain intraocular pressure, or promote patient comfort. DIF: Cognitive Level: Application REF: Page 90 OBJ: N/A TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 14. The nurse is instructing a patient to use a corticosteroid inhaler. Which statement by the patient indicates the need for further teaching? a. “I will shake the inhaler before I use it.” b. “I need to rinse my mouth after I use the inhaler.” c. “I will use this when I’m lying in bed in the morning.” d. “After I inhale, I will hold my breath and then breathe out slowly.” ANS: C The sitting position allows for maximum lung expansion. Shaking the inhaler helps to disperse the medication. The mouth needs to be rinsed after the inhalation of a corticosteroid. Holding the breath then exhaling slowly allows the drug to settle into pulmonary tissue. DIF: Cognitive Level: Application REF: Page 94 OBJ: 7 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education; Health Promotion 15. What is the appropriate nursing action when administering a vaginal suppository? a. Ask the patient to urinate prior to insertion. b. Assist the patient to a side-lying position. c. Keep suppository refrigerated prior to insertion. d. Insert the suppository 1 inch into the vagina. ANS: A An empty bladder facilitates insertion. A side-lying position would not facilitate insertion of a vaginal suppository. The suppository needs to be warmed to room temperature before it is administered. The suppository is inserted more than 1 inch. DIF: Cognitive Level: Application REF: Page 97 OBJ: 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 16. Which is an accurate nursing action when treating a patient’s rash with a lotion? a. Avoid shaking the container prior to application. b. Cleanse area with alcohol prior to treatment. c. Cover the area with gauze because of the oil base. d. Pat on the area with a gloved hand. ANS: D To prevent increased circulation and itching, lotions should be gently but firmly patted on the skin, rather than rubbed in. Shake all lotions thoroughly immediately before application. Lotions are aqueous and are easily cleansed with water. Lotions are not oil based. DIF: Cognitive Level: Application REF: Page 81 OBJ: 1 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 17. A 2-year-old child is hospitalized with the diagnosis of tonsillitis and bilateral otitis media. The nurse is preparing to administer eardrops. When instilling the eardrops, the nurse will pull the earlobe a. upward and back. b. sideways and down. c. downward and back. d. sideways and up. ANS: C For children under 3 years, pull the earlobe downward and back with eardrop instillation to straighten the external auditory canal. The earlobe is pulled up and back for adults and children ages 3 and over. DIF: Cognitive Level: Comprehension REF: Page 91 OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Development 18. The nurse is preparing an otic solution. When instructing the patient in regard to area of administration, the nurse will explain that the solution will be placed a. into the eye. b. under the tongue. c. topically. d. into the ear. ANS: D Medications for use in the ear are labeled otic. Ophthalmic solutions are administered into the eye. Sublingual medications are administered under the tongue. Topical medications are applied to the skin. DIF: Cognitive Level: Application REF: Page 91 OBJ: 6 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Patient Education MULTIPLE RESPONSE 1. Which order(s) would be examples of percutaneous medication administration? (Select all that apply.) a. Timolol 0.5% 1 drop to each eye daily b. Albuterol nebulizer 2.5 mg qid c. Heparin 5000 units IV d. Lasix 20 mg PO every AM e. Silvadene 1% topically to affected area ANS: A, B, E Percutaneous administration refers to applying medications to the skin or mucous membranes for absorption, such as eyedrops. DIF: Cognitive Level: Application REF: Page 81 OBJ: 1 | 7 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 2. Which action(s) will the nurse perform when preparing to administer a topical medication? (Select all that apply.) a. Wash hands before and after administration. b. Maintain a dry environment to encourage wound healing. c. Wear gloves during the application process. d. Use sterile dressings for all wounds. ANS: A, C Handwashing is an essential part of medication administration. Gloves are worn with topical medication to prevent absorption into the practitioner’s own skin. Dryness does not encourage wound healing. Sterile dressings do not work well for all wounds. DIF: Cognitive Level: Application REF: Page 82 OBJ: 1 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion 3. Which dressings would be appropriate to use for treating wounds with exudates? (Select all that apply.) a. AlgiDERM b. Telfa c. Kaltostat d. Sorbsan e. OpSite ANS: A, C, D AlgiDERM, Kaltostat, and Sorbsan are exudate absorbers for use in treating infected wounds. Telfa and OpSite are not appropriate to use on wounds with exudates. DIF: Cognitive Level: Knowledge REF: Page 82 OBJ: 1 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion ORDERING 1. Place the following steps for administration of nose drops in the correct order. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.) a. Draw medication into the dropper. b. Instruct patient to blow the nose gently. c. Review practice setting policy. d. Explain the steps to the patient. e. Position the patient into supine position with head backward over edge of bed. f. Instill medication. ANS: C, D, B, E, A, F DIF: Cognitive Level: Analysis REF: Page 92 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion; Patient Education Chapter 11: Parenteral Administration: Intravenous Route Clayton/Willihnganz: Basic Pharmacology for Nurses, 17th Edition MULTIPLE CHOICE 1. A patient is diagnosed with cancer and requires 6 months of chemotherapy infusions. Which type of intravenous (IV) access device will likely be used? a. Peripheral venous access device b. Midline catheter c. Winged needle venous access device d. Implantable venous infusion port ANS: D Implantable venous infusion ports are placed into central veins for long term therapy. Chemotherapy treatment is often irritating and best tolerated in the larger central veins. Peripheral lines are not used for administration of chemotherapy because of the risk of extravasation. A midline catheter is intended only for a 2 to 4 week interval, less than the projected length of time for chemotherapy infusion. Winged needles are for use in peripheral veins that are too small for ongoing infusion of chemotherapy. DIF: Cognitive Level: Application REF: Page 147 | Page 149 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment 2. The nurse notes that a patient with cardiac disease has IV heparin infusing and that it is behind by 2 hours. What is the best nursing action? a. Increase the IV rate and recheck in 1 hour. b. Change the infusion rate to TKO. c. Discontinue the solution using aseptic technique. d. Contact the health care provider for consultation. ANS: D The patient has a history of cardiac problems and is receiving a critical care medication, IV heparin. In this case, contacting the patient’s health care provider would be appropriate to avoid harm. Increasing the infusion rate might place the patient into fluid overload and might infuse too much heparin in a short time. Reducing the infusion rate to TKO or discontinuing the solution would put the schedule even further behind. DIF: Cognitive Level: Application REF: Page 154 OBJ: 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Collaboration; Communication 3. What is the composition of hypotonic intravenous solutions such as 0.45% NaCl? a. Fewer dissolved particles than blood b. Approximately the same number of dissolved particles as blood c. Higher concentrations of dissolved particles than blood d. Electrolytes and dextrose ANS: A Hypotonic solutions have fewer dissolved particles than blood. Half normal saline does not contain dextrose. DIF: Cognitive Level: Knowledge REF: Page 150 OBJ: 3 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation 4. Which condition would the nurse expect to be treated with an isotonic solution? a. Fluid overload b. Hemorrhagic shock c. Cellular dehydration d. Cerebral edema ANS: B Isotonic solutions have approximately the same osmolality as blood. Isotonic fluids are ideal replacement fluids for patients experiencing an intravascular fluid deficit that occurs in conditions such as acute blood loss from hemorrhage and gastrointestinal bleeding. Isotonic fluids increase vascular volume, thus counteracting hypovolemia and hypotension. Administering isotonic solutions for fluid overload would exacerbate the problem. Hypotonic solutions are administered for cellular dehydration. Hypertonic solutions are administered for cerebral edema. DIF: Cognitive Level: Application REF: Page 150 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation 5. The nurse determines that an elderly patient’s IV of D50.2 NS with 20 mEq KCl at 75 mL/hr is running 3 hours behind. After determining the IV site is patent, what action will the nurse take? a. Call the health care provider to obtain an order to decrease the IV rate. b. Administer a bolus to make up the deficit. c. Recalculate the flow rate and slowly make up the fluids. d. Maintain the ordered rate. ANS: D The safest action is to maintain the ordered rate. The health care provider should be consulted if the patient has not received critical IV replacement therapy. Increasing an IV rate without a health care provider’s order can be detrimental for patients who have cardiac, renal, or circulatory impairment. Normal aging process results in decreased cardiac, renal, and circulatory function. The rate ordered is the one the provider intended for the administration of fluids; changing it to fit the prevailing situation is not appropriate. The bolus technique should only be used for the administration of medications or fluid challenges in patients who need a volume of IV fluid quickly. The flow rate must be consistent with the provider’s order. DIF: Cognitive Level: Application REF: Page 154 OBJ: 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation 6. Which technique by the nurse accurately maintains asepsis of a peripheral IV access device? a. Wear gloves when hanging all IV solutions. b. Apply a topical antibiotic ointment to the insertion site. c. Change fluid administration sets according to institutional policy. d. Flush with heparin before use. ANS: C Generally all IV solution bag and bottles should be changed every 24 hours to minimize the development of new infections. IV administration sets used to deliver blood and blood products are changed after each unit is administered. Administration sets to deliver lipids and TPN are often changed every 4 hours, whereas administration sets for maintenance fluids may be changed every 72 hours. It is important to follow institutional policies. All IV bags, bottles, and administration sets should be labeled with the date, time, and nurse’s initials of the set change. Wearing gloves is not required for maintenance of routine infusion. Topical antibiotics may promote fungal infections and antimicrobial resistance. A peripheral line that is infusing should not need an anticoagulant to maintain patency. DIF: Cognitive Level: Application REF: Page 153 OBJ: 8 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Health Promotion 7. Which needle is used to access implanted infusion devices? a. Jamshidi b. Huber c. Gigli d. Crutchfield ANS: B The Huber needle is a special noncoring 90-degree needle used to penetrate the skin and septum of the implanted device. The Jamshidi needle is used for biopsy purposes such as bone marrow. The Gigli saw is a wire with serrations used to cut through cranial bone. Crutchfield tongs are used to stabilize the cervical spine by traction in cases of fracture. DIF: Cognitive Level: Comprehension REF: Page 149 OBJ: 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment 8. The nurse assesses erythema, warmth, and burning pain along the patient’s IV site. Which complication is this patient most likely experiencing? a. Air embolism b. Extravasation c. Phlebitis d. Pulmonary edema ANS: C Erythema, warmth, and tenderness along the course of the vein and swelling are signs of phlebitis. Air embolism occurs as a result of an air bubble entering the vascular system, and shortness of breath, chest pain, and hypotension are indicative of this complication. Extravasation is the leakage of an irritant and is accompanied by redness, warmth or coolness, swelling, and a dull ache to severe pain at the venipuncture site. Pulmonary edema is caused by fluid infusing too rapidly; dyspnea, cough, anxiety, rales, and possible cardiac dysrhythmias are indicative of pulmonary edema. DIF: Cognitive Level: Comprehension REF: Page 171 OBJ: 9 TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity; Perfusion 9. An elderly patient receiving an infusion of an isotonic fluid at 100 mL/hr complains of dyspnea. The nurse notes shallow rapid respirations and a cough that produces frothy sputum. Which is the priority nursing action? a. Assess the urine output. b. Elevate the head of the bed. c. Encourage the patient to cough. d. Maintain the IV rate. ANS: B Elevating the head of the bed is an appropriate action for signs and symptoms of pulmonary edema. Urine output is important to assess, but it is not the priority nursing action. Encouraging the patient to cough and take deep breaths is not the priority nursing action. The IV rate should be slowed immediately based on the signs and symptoms the patient is displaying. DIF: Cognitive Level: Application REF: Page 172 OBJ: 9 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Fluid Electrolyte Balance; Perfusion 10. A diabetic patient requires the administration of insulin continuously at home. Which system would most likely be used in this instance? a. Central line catheter b. Microdrip set c. Piggyback system d. Syringe pump ANS: D Syringe pumps are used in patients with diabetes. A central line is not appropriate for the diabetic patient requiring insulin. A microdrip set is a type of IV tubing that is used when small volumes of fluid are given to patients with fluid volume concerns. A piggyback system is a type of administration set that connects to a primary setup and administers a small volume over 20 to 60 minutes. DIF: Cognitive Level: Application REF: Page 147 OBJ: 2 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety 11. A patient is admitted with hypovolemia resulting from lack of fluid intake and requires an infusion of isotonic fluids. Which IV solution will the nurse administer? a. D50.2 NS b. D5W c. 0.45 NS d. 0.9 NS ANS: D 0.9 NS is an isotonic solution appropriate for hypovolemia. D50.2 NS, D5W, and 0.45 NS are hypotonic solutions. DIF: Cognitive Level: Comprehension REF: Page 150 OBJ: 3 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Fluid and Electrolyte Balance; Cellular Regulation 12. Which potential complication will the nurse expect in patients with a venous access device? a. Circulatory overload b. Extravasation c. Infection d. Pain ANS: C Because venipuncture alters skin integrity, the patient is vulnerable to infection at all times. Circulatory overload is a concern but does not occur with any type of venous access device because the device may just be used for administration of small volumes of drugs (e.g., chemotherapy in cancer patients). Extravasation is a potential complication when there is infusion of an irritating chemical. IV drug administration is usually more comfortable for patients than other routes, and pain would not be considered a complication. DIF: Cognitive Level: Application REF: Page 171 OBJ: 9 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity 13. A patient has a peripherally inserted central catheter (PICC) line inserted to continue IV antibiotic therapy at home. With proper care, how long can this type of venous access device remain in place? a. 2 months b. 4 months c. 6 months d. 12 months ANS: D PICC lines routinely remain in place for 1 to 3 months but can last for a year or more if cared for properly. DIF: Cognitive Level: Knowledge REF: Page 148 OBJ: 2 | 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Infection; Tissue Integrity 14. In assessing a patient with a central venous access device, which sign or symptom indicates that the patient is experiencing an air embolism? a. Chest pain b. Erythema c. Frothy sputum d. Sweating ANS: A Chest pain is a symptom associated with air embolism. Erythema occurs with infiltration or extravasation. Frothy sputum occurs with circulatory overload or pulmonary edema. Sweating is indicative of a pulmonary embolism. DIF: Cognitive Level: Application REF: Page 172 OBJ: 9 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Gas Exchange 15. Following the insertion of a central venous access device, the nurse notes a weak, thready pulse and decreased blood pressure. The patient complains of shortness of breath and palpitations. Which action will the nurse take first? a. Place the patient on the left side. b. Reassess vital signs. c. Stop the infusion. d. Verify placement of the device. ANS: A Signs and symptoms indicate an air embolism. The nurse’s immediate action will be to place the patient onto his or her left side. The nurse has determined change in pulse and blood pressure already, and although it is appropriate to reassess, it is not the first action the nurse will take. There is no indication that anything is infusing into this venous access device. Verifying the placement of the device is not the first action the nurse would take. DIF: Cognitive Level: Application REF: Page 172 OBJ: 9 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Gas Exchange 16. The nurse is about to administer a prescribed medication IV push into a patient's Hickman catheter. When providing this medication, the nurse will first a. administer the prescribed drug. b. flush with saline. c. flush with heparin. d. prepare a pump. ANS: B Drugs given by IV push or bolus through a Hickman catheter generally follow the SASH guideline: saline flush first; administer the prescribed drug; saline flush following the drug; heparin flush line. A pump is not used when a drug is administered by push technique. DIF: Cognitive Level: Application REF: Page 154 OBJ: 2 | 4 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment| NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Health Promotion 17. A 90-year-old woman is admitted to an acute care facility with the diagnosis of pneumonia. She has a past medical history of diabetes mellitus, hypertension, and right-sided mastectomy. When starting an IV for infusion of antibiotic therapy, the nurse will a. insert the IV catheter into the left hand. b. use a lower extremity vein for insertion. c. choose the left radial artery for insertion. d. attempt insertion into the left antecubital space vein. ANS: D IV insertion should not be initiated in an arm with compromised lymphatic or venous flow such as a mastectomy. The left antecubital space vein would be a good choice for this patient given her age and medical history. In the older adult, using the veins in the hand area may be a poor choice because of the fragility of the skin and veins in this area. When possible, the veins of the lower extremities should be avoided for IV insertion because of the danger of developing thrombi and emboli. IV therapy should never be started in an artery. DIF: Cognitive Level: Application REF: Page 154 OBJ: 4 | 5 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe, Effective Care Environment NOT: CONCEPT(S): Clinical Judgment; Safety; Perfusion; Tissue Integrity MULTIPLE RESPONSE 1. What will the nurse explain when teaching a patient about a PICC line? (Select all that apply.) a. The catheter may have a single or double lumen. b. There is greater risk of clotting and infiltration with this type of catheter. c. The patient will be receiving infusions continuously to ensure patency. d. The tip of the catheter may be open or valved. e. The catheter may be used for drawing blood. ANS: A, D PICC lines may have more than one lumen. The catheter may have an open tip or a valved (Groshong) tip. The risk of infiltration and clotting is less than with other types of central lines. The line should be flushed with a saline heparin solution after every use, or daily, in order to maintain patency if it is not in continuous use. PICC lines are not appropriate for blood drawing because of their small size. DIF: Cognitive Level: Comprehension REF: Page 148 OBJ: 2 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Patient Education 2. Which patient assessment finding(s) suggest(s) extravasation of an IV solution? (Select all that apply.) a. Coolness b. Edema c. Fever d. Pain at venipuncture site e. Redness at the site f. Shortness of breath ANS: A, B, D, E Coolness, edema, pain, and redness are indicative of extravasation. Fever does not indicate extravasation. Shortness of breath does not indicate extravasation. DIF: Cognitive Level: Comprehension REF: Page 171 OBJ: 9 TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Tissue Integrity 3. The nurse assesses a patient’s right hand IV site to be infiltrated. Appropriate nursing actions include (Select all that apply.) a. stopping the infusion. b. attempting to aspirate the medication. c. elevating the affected limb. d. checking capillary refill. e. removing the catheter as directed by policy. ANS: A, C, D, E For an infiltration, stop the infusion. Elevate the affected limb. Assess for circulatory compromise; check capillary refill and pulses proximal and distal to the area of infiltration. If the infiltration is caused by an IV solution, remove the catheter as directed by policy. For extravasation, attempts may be made to aspirate the medication. DIF: Cognitive Level: Analysis REF: Page 171 | Page 172 OBJ: 9 TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity NOT: CONCEPT(S): Clinical Judgment; Safety; Tissue Integrity