NURS 3303 EXAM 2, END OF CHAPTER QUESTIONS WITH RATIONALES LATEST UPDATE
2025/2026
A nurse is administering an oral tablet to a patient. Which of the following steps is the second
check for accuracy in determining the patient is receiving the right medication? - Answers -
Before going to a patient's room, compare the patient's name and name of medication on label
of prepared drugs with MAR.
Rationale: This is the second check for accuracy before leaving to the medication preparation
area. The first accuracy check occurs when you check the label of medication against the MAR
when removing the unit dose or automated medication dispensing systems. The third check
occurs at the patient's bedside when you comare the MAR or computer printout with the names
of medicaitons on medicaiton labels.
The health care provider has written the following orders. Which order(s) does the need need to
clarify before administering the medication? Select all that apply. - Answers The nurse
questions ALL of the orders.
1. Timoptic.25 % solution 1 drop OD BID
Rationale: There is a naked decimal point, also OD (right eye) could be mistaken for AD (right
ear).
Rationale: It should be correctly written as Timoptic 0.25% solution 1 drop right eye BID.
2. Metoprolol 12.50 mg QD
Rationale: Has a trailing zero, and the dosage could be mistaken for 1250 if the decimal point is
not see and there is no route identified. It should be correctly written as Metoprolol 12.5mg QD
PO.
3. Insulin Glargine 6 u SC twice a day
Rationale: The letter u (for units) could be mistaken as the number 0 or 4 and SC could be
mistaken as SL. It should be written as Insulin glargine 6 units subcutaneous twice a day
4. Enalapril 2.5mg. PO 3 times a day, hold for systolic blood pressure < 100.
Rationale: There is a period after the units, mg, which could be mistaken as the number 1 and
the < sign could be mistake as greater than.It should be written as Enalapril 2.5mg PO 3 times a
day, hold for systolic blood pressure less than 100
An older adult states that she cannot see her medication bottles clearly to determine when to
take her prescription. What actions should the nurse take to help the older adult patient? Select
all that apply. - Answers - Provide a dispensing system for each day of the week
- Provide larger, easier-to-read labels
,- Use teach-back to ensure the patient knows what medication to take and when
Which of the following guidelines must a nurse use for taking verbal or telephone orders? -
Answers - Follow the health care agency guidelins regarding authorized staff who may receive
and record verbal or telephone orders
- Clearly identify patient's name, room number, and diagnosis
- Read back all orders to health care provider
- Use clarification questions to avoid misunderstandings
- Write "VO" verbal order, or "TO" telephone order, including data and time, name of patient, and
complete order; sign the name of health care provider and nurse
Which aspects of the patient's care related to the administration of heparin can the nurse
delegate to the nursing AP? Select all that apply. - Answers - Notify the nurse of any signs of
bleeding
- Notify the nurse if there is blood in the patient's urine
- Notify the nurse for oozing from the puncture sites
Which of the following signs or symptoms in a patient who is opioid naive is of greatest concern
to the nurse when assessing the patient 1 hour after administering an opoid? - Answers -
Difficulty arousing the patient
- Rationale: Sedation is a concern because it may indicate that the patient is experiencing opioid
-related side effects, advancing sedation may indicate patient may progress to respiratory
depression.
A nurse is administering an MDI with a spacer to a patient with COPD. Place the steps in the
following appropiate order. - Answers 1. Perform a respiratory assessment
2. Remove mouthpiece from MDI and spacer device
3. Shake inhaler for 2 to 5 seconds
4. Insert MDI into end of spacer.
5. Place spacer mouthpiece into patient's mouth and instruct patient to close lips around the
mouthpiece.
6. Depress medicaiton canister, spraying 1 puff into spacer device
7. Instruct patient to breath in slowly through mouth for 3 to 5 seconds
8. Instruct patient to hold breath for 10 seconds
, A patient is to receive medications through a small-bore nasogastric feeding. Which nursing
actions are appropiate? Select all that apply. - Answers - Using an enteral tube syringe to
adminsiter medication (necessary to avoid dangerous misconnections and accidently
administering through another tube)
- Flushing tube with 30 to 60 mL of water after last medication dose (clears tube of any residual
medication and ensures tube remains patent)
- Checking for gastric residual before giving medication
- Keeping head of bed elevated for 30 to 60 minutes after the medications are given
Place the steps of administering an intradermal injection in the correct order. - Answers 1.
Cleanse site with antiseptic swab
2. Using nondominant hand, stretch skin over site with forefinger
3. Insert needle at 5 to 15 degree angle until resistance is felt
4. Advance needle through epidermis to 3mm
5. Inject medication slowly
6. Note bleb presence
After receiving IM injection in the deltoid, a patient states, "My arm really hurts. It's burning and
tingling where I got my injection." What should the nurse do next? Select all that apply. -
Answers - Assess the injection site
- Notify the patient's health care provider of assessment findings (important in case there is an
adverse effect)
- Document assessment findings and related interventions in the patient's medical record (nurse
must always document adverse effects so the site and patient can be monitored)
A nurse is instructing a patient who has decreased leg strength on the left side on how to use a
cane. Which actions indicates proper cane use by the patient? - Answers - The patient keeps
two points of support on the floor at all times.
- The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.
Rationale: The patient learns that two points of support such as both feet or one foot and the
cane are on the floor at ALL times. The patient moves the weaker leg forward to the cane so the
body weight is divided between the cane and stronger leg.
A patient is admitted to a rehabiliation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with one-
2025/2026
A nurse is administering an oral tablet to a patient. Which of the following steps is the second
check for accuracy in determining the patient is receiving the right medication? - Answers -
Before going to a patient's room, compare the patient's name and name of medication on label
of prepared drugs with MAR.
Rationale: This is the second check for accuracy before leaving to the medication preparation
area. The first accuracy check occurs when you check the label of medication against the MAR
when removing the unit dose or automated medication dispensing systems. The third check
occurs at the patient's bedside when you comare the MAR or computer printout with the names
of medicaitons on medicaiton labels.
The health care provider has written the following orders. Which order(s) does the need need to
clarify before administering the medication? Select all that apply. - Answers The nurse
questions ALL of the orders.
1. Timoptic.25 % solution 1 drop OD BID
Rationale: There is a naked decimal point, also OD (right eye) could be mistaken for AD (right
ear).
Rationale: It should be correctly written as Timoptic 0.25% solution 1 drop right eye BID.
2. Metoprolol 12.50 mg QD
Rationale: Has a trailing zero, and the dosage could be mistaken for 1250 if the decimal point is
not see and there is no route identified. It should be correctly written as Metoprolol 12.5mg QD
PO.
3. Insulin Glargine 6 u SC twice a day
Rationale: The letter u (for units) could be mistaken as the number 0 or 4 and SC could be
mistaken as SL. It should be written as Insulin glargine 6 units subcutaneous twice a day
4. Enalapril 2.5mg. PO 3 times a day, hold for systolic blood pressure < 100.
Rationale: There is a period after the units, mg, which could be mistaken as the number 1 and
the < sign could be mistake as greater than.It should be written as Enalapril 2.5mg PO 3 times a
day, hold for systolic blood pressure less than 100
An older adult states that she cannot see her medication bottles clearly to determine when to
take her prescription. What actions should the nurse take to help the older adult patient? Select
all that apply. - Answers - Provide a dispensing system for each day of the week
- Provide larger, easier-to-read labels
,- Use teach-back to ensure the patient knows what medication to take and when
Which of the following guidelines must a nurse use for taking verbal or telephone orders? -
Answers - Follow the health care agency guidelins regarding authorized staff who may receive
and record verbal or telephone orders
- Clearly identify patient's name, room number, and diagnosis
- Read back all orders to health care provider
- Use clarification questions to avoid misunderstandings
- Write "VO" verbal order, or "TO" telephone order, including data and time, name of patient, and
complete order; sign the name of health care provider and nurse
Which aspects of the patient's care related to the administration of heparin can the nurse
delegate to the nursing AP? Select all that apply. - Answers - Notify the nurse of any signs of
bleeding
- Notify the nurse if there is blood in the patient's urine
- Notify the nurse for oozing from the puncture sites
Which of the following signs or symptoms in a patient who is opioid naive is of greatest concern
to the nurse when assessing the patient 1 hour after administering an opoid? - Answers -
Difficulty arousing the patient
- Rationale: Sedation is a concern because it may indicate that the patient is experiencing opioid
-related side effects, advancing sedation may indicate patient may progress to respiratory
depression.
A nurse is administering an MDI with a spacer to a patient with COPD. Place the steps in the
following appropiate order. - Answers 1. Perform a respiratory assessment
2. Remove mouthpiece from MDI and spacer device
3. Shake inhaler for 2 to 5 seconds
4. Insert MDI into end of spacer.
5. Place spacer mouthpiece into patient's mouth and instruct patient to close lips around the
mouthpiece.
6. Depress medicaiton canister, spraying 1 puff into spacer device
7. Instruct patient to breath in slowly through mouth for 3 to 5 seconds
8. Instruct patient to hold breath for 10 seconds
, A patient is to receive medications through a small-bore nasogastric feeding. Which nursing
actions are appropiate? Select all that apply. - Answers - Using an enteral tube syringe to
adminsiter medication (necessary to avoid dangerous misconnections and accidently
administering through another tube)
- Flushing tube with 30 to 60 mL of water after last medication dose (clears tube of any residual
medication and ensures tube remains patent)
- Checking for gastric residual before giving medication
- Keeping head of bed elevated for 30 to 60 minutes after the medications are given
Place the steps of administering an intradermal injection in the correct order. - Answers 1.
Cleanse site with antiseptic swab
2. Using nondominant hand, stretch skin over site with forefinger
3. Insert needle at 5 to 15 degree angle until resistance is felt
4. Advance needle through epidermis to 3mm
5. Inject medication slowly
6. Note bleb presence
After receiving IM injection in the deltoid, a patient states, "My arm really hurts. It's burning and
tingling where I got my injection." What should the nurse do next? Select all that apply. -
Answers - Assess the injection site
- Notify the patient's health care provider of assessment findings (important in case there is an
adverse effect)
- Document assessment findings and related interventions in the patient's medical record (nurse
must always document adverse effects so the site and patient can be monitored)
A nurse is instructing a patient who has decreased leg strength on the left side on how to use a
cane. Which actions indicates proper cane use by the patient? - Answers - The patient keeps
two points of support on the floor at all times.
- The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.
Rationale: The patient learns that two points of support such as both feet or one foot and the
cane are on the floor at ALL times. The patient moves the weaker leg forward to the cane so the
body weight is divided between the cane and stronger leg.
A patient is admitted to a rehabiliation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with one-
