The nurse is administering heparin via the subcutaneous route. Which intervention should
Prepare the medication using a 25-gauge, ½ inch needle
the nurse implement?
Knowledge: The nurse should NOT aspirate for blood when administering heparin because
a. Prepare the medication using a 25-gauge, ½ inch needle
this can damage surrounding tissue and cause bruising. The nurse should not massage after
b. After injecting the needle, aspirate and observe for blood
injecting heparin because this may cause bruising or bleeding. Heparin is administered in
c. After removing the needle, massage the area gently
the abdomen at least 2 inches from umbilicus-best practice.
d. Administer the medication in the client's "love handles"
a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus
The nurse is administering morning medications on a medical floor. Which medication should b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus (can
the nurse administer first? be administered within the 30-minute acceptable time frame)
c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS -pain medication is a priority,
a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus but it can be administered after the sliding scale
b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus d. Lasix, a diuretic, to a client with hypertension- can be administered within the 30-minute
c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS acceptable time frame
d. Lasix, a diuretic, to a client with hypertension Regular insulin is administered prior to meals; therefore, this medication should be admin-
istered. Critical Thinking
Which data would indicate that the antibiotic therapy has been successful for a client diag- a. The client's hematocrit is within normal range- does not indicate client response
nosed with bacterial pneumonia? b. The client is expectorating thick green sputum- symptom of pneumonia
c. The client's lung sounds are clear to ausculatation
a. The client's hematocrit is within normal range d. The client has complaints of pleuritic chest pain.— symptom of pneumonia
b. The client is expectorating thick green sputum The symptoms of pneumonia includes crackles and wheezes, rhonchi in the lung fields.
c. The client's lung sounds are clear to ausculatation Clear lungs indicate an improvement in the pneumonia and that the medication is ettective.
d. The client has complaints of pleuritic chest pain. Application
a. Ensure the client eats at least 90% of the lunch tray—insulin will not be working 4-5 hours
after being administered
The nurse is administering Humalog at 0730 to a client diagnosed with Type 1 diabetes. Which
b. Do not administer unless the breakfast tray is in the client's room
intervention should the nurse implement?
c. Check the client's blood glucose level 1 hour after receiving the insulin—glucose level
should be checked prior to administering
a. Ensure the client eats at least 90% of the lunch tray
d. Have 50% dextrose in water at the bedside for emergency use.—this is administered when
b. Do not administer unless the breakfast tray is in the client's room
a client is unconscious secondary to hypoglycemia, and should not be kept at the bedside.
c. Check the client's blood glucose level 1 hour after receiving the insulin
Orange juice or some form of simple glucose can be kept at the bedside.
d. Have 50% dextrose in water at the bedside for emergency use.
Application: The insulin peaks in 15-20 minutes after being administered; therefore, the meal
should be at the bedside prior to administering this medication
a. Wear an insect repellent on exposed skin —appropriate intervention, but if the client has
an insect bite, the repellent will not prevent anaphylaxis, therefore, not priority intervention
The client has a severe anaphylactic reaction to insect bites. What priority discharge inter-
b. Keep prescribed antihistamines on their person —used with anaphylaxis, but it takes at
vention should the nurse discuss with the client?
least 30 minutes to work, therefore not a priority medication
a. Wear an insect repellent on exposed skin c. Keep an EpiPen in the refrigerator at all times —keeping medication in the refrigerator
b. Keep prescribed antihistamines on their person does not allow it to be available to the client at all times.
c. Keep an EpiPen in the refrigerator at all times d. Wear a MedicAlert identification bracelet
d. Wear a MedicAlert identification bracelet
Application: Bracelet indicates the client is at risk for an anaphylactic reaction; therefore, this
is the priority intervention.
The client's mother contacts the clinic regarding medication administration stating, "My
d. Stop the medication and inform the physician
daughter cannot swallow this capsule. It's too large." Investigation reveals that the medication
is a capsule marked SR. The nurse should instruct the mother to: Application: SR means sustained released. These medications cannot be altered. In answers A
and B, crushing or opening the capsule is not allowed. The best response would be to inform
a. Open the capsule and mix the medication with apple sauce
the prescriber (the doctor) immediately
b. Crush the medication and administer it with a glass of liquid
, c. Call the pharmacist and request a change to a ditterent medication
d. Stop the medication and inform the physician
a. Administer the client's prescribed pain medication —should not administer pain medica-
The client calls the nursing station and requests pain medication. When the nurse enters the tion until after assessing the client's pain
room with the narcotic medication, the nurse finds the client laughing and talking with visitors. b. Assess the client's perception of pain on a 1-10 scale
Which action should the nurse administer first? c. Wait until the visitors leave to administer any medication —should assess client whether
the client has visitors or not
a. Administer the client's prescribed pain medication d. Check the MAR to see if there is a nonnarcotic medication ordered —nurse should assess
b. Assess the client's perception of pain on a 1-10 scale the client's pain first
c. Wait until the visitors leave to administer any medication
d. Check the MAR to see if there is a nonnarcotic medication ordered Application: first action is to always assess the client in pain to determine if client is having a
complication that requires medical intervention rather than PRN medication.
The client in hypovolemic shock is receiving normal saline by rapid intravenous infusion. a. The client's blood pressure is 89/48
Which assessment data would warrant immediate intervention by the nurse? b. The client's pulse oximeter reading is 95% --normal finding
c. The client's lung sounds are clear bilaterally—normal finding
a. The client's blood pressure is 89/48 d. The client's urine output is 120 mL in 3 hours—normal finding
b. The client's pulse oximeter reading is 95%
c. The client's lung sounds are clear bilaterally Application: low blood pressure reading for a client in hypovolemic shock. A B/P less than
d. The client's urine output is 120 mL in 3 hours 90/60 warrants intervention by the nurse and indicates that fluid resuscitation is not ettective.
a. Insert the needle with the bevel up at 15-degree angle in the skin
Which intervention should the nurse implement when administering a medication via the b. Prepare the medication in a 3-mL syringe using a 23-gauge 1-inch needle —wrong syringe
intradermal route? (need tuberculin syringe), wrong gauge, and wrong needle
c. Bunch the skin between the thumb and index finger of the nondominant hand---skin should
a. Insert the needle with the bevel up at 15-degree angle in the skin be spread taut, not bunched
b. Prepare the medication in a 3-mL syringe using a 23-gauge 1-inch needle d. Quickly inject the medication as to not form a wheal or bleb—medication should be
c. Bunch the skin between the thumb and index finger of the nondominant hand injected slowly to form a wheal or bleb
d. Quickly inject the medication as to not form a wheal or bleb
Knowledge: A is the correct way to administer intradermal medication
a. Stop the primary nurse and ask the nurse to step out of the room
The charge nurse is observing the primary nurse administering otic drops to a 2-year-old
b. Demonstrate inserting the otic drops by pulling up and back on the auricle—correct way
child by pulling down and back on the auricle. Which action should the charge nurse take?
for adults
a. Stop the primary nurse and ask the nurse to step out of the room c. Take no action because this is the correct way to administer the ear drops
b. Demonstrate inserting the otic drops by pulling up and back on the auricle d. Allow the nurse to administer the otic drops and then discuss the technique with the nurse
c. Take no action because this is the correct way to administer the ear drops Knowledge: This is the correct way to administer eardrops to a child younger than 3. This is
Allow the nurse to administer the otic drops and then discuss the technique with the nurse
d. done because of the short Eustachian tube of a child. The charge nurse need take no action
a. Explain that the medication must be administered because it has been drawn up —client
The nurse prepared 2 mg of morphine for a client who is complaining of pain. When the nurse has the right to refuse medication; therefore; the nurse cannot force the client to take the
enters the room the client tells the nurse, "I don't want to take a shot. I would like to have a med.
pain pill." Which action should the nurse take? b. Ask another nurse to watch the medication being wasted into the sink
c. Place the syringe in the sharps container in the client's room—legally the nurse must have
a. Explain that the medication must be administered because it has been drawn up someone witness the narcotic being wasted
b. Ask another nurse to watch the medication being wasted into the sink d. Notify the pharmacy that a narcotic was not administered to the client—does not need to
c. Place the syringe in the sharps container in the client's room— be notified
d. Notify the pharmacy that a narcotic was not administered to the client
Application: Correct procedure as per CNO medication standards of practice
a. The deltoid muscle —1-2 mL max. at this site, muscle is small
The nurse is preparing to adminster 3 mL of a medication intramuscularly to an adult client
b. The dorsogluteal muscle— not recommended because the sciatic nerve may be injured if
in the clinic. Which muscle is the best site to administer the medication?
landmarking is improper
c. The ventrogluteal muscle
, a. The deltoid muscle d. The vastus lateralis muscle— can be used, but is more painful
b. The dorsogluteal muscle
c. The ventrogluteal muscle Knowledge: site of choice is C, free of major nerves and adipose tissue to ensure medication
d. The vastus lateralis muscle goes in the muscle. It is also a larger mass of muscle.
The nurse is administering medications through a gastrostomy tube (GT). Which intervention a. Place the crushed pills in the gastrostomy tube.—Not first intervention
should the nurse implement first? b. Flush the gastrostomy with at least 30 mL of tap water
c. Use the plunger to push the medication into the GT- not first intervention
a. Place the crushed pills in the gastrostomy tube. d. Clamp the gastrostomy tube closed.— performed after medication is administered
b. Flush the gastrostomy with at least 30 mL of tap water
c. Use the plunger to push the medication into the GT Knowledge: Nurse should first flush the GT with tap water to ensure it is patent before putting
d. Clamp the gastrostomy tube closed. any medication into the GT.
a. Administer the client's medications—charge nurse cannot administer without verifying
The charge nurse is making rounds on the clients and notices the primary nurse left a
medications against MAR
medication cup with three tablets at the client's bedside. Which action should the charge
b. Remove the medication cup from the room
nurse implement?
c. Request the primary nurse come to the room—charge nurse should not correct the primary
a. Administer the client's medications nurse in front of client
b. Remove the medication cup from the room d. Leave the cup at the bedside and talk to the primary nurse
c. Request the primary nurse come to the room
Application: The nurse should take the medication cup back to the medication room and
d. Leave the cup at the bedside and talk to the primary nurse
discuss this situation with the primary nurse. Medications should never be left at the bedside.
a. The client's serum potassium level is 5.8 mEq/L
1. The client in end-stage renal disease is receiving oral Kayexalate. Which assessment data
b. The client's serum sodium level is 135 mEq/L —does not alter sodium levels (not used for
indicates the medication is not ettective?
this)
a. The client's serum potassium level is 5.8 mEq/L c. The client's serum postassium level is 4.2 mEq/L—normal level
b. The client's serum sodium level is 135 mEq/L d. The client's serum sodium level is 147 mEq/L (see above)
c. The client's serum postassium level is 4.2 mEq/L
Application: Kayexalate is a medication used to decrease potassium levels. A is an elevated
d. The client's serum sodium level is 147 mEq/L
level, therefore, medication is not ettective.
b. Intravenous aminophylline
Which of the following interventions would be a priority in the plan of care for the person with
c. Maintain hydration status
pulmonary emphysema? (Select all that apply)
Application Question: Since emphysema is a chronic disorder, the patient will be required to
a. Low flow oxygen via face mask
wear oxygen continuously, therefore nasal canula is the best way to deliver the low levels
b. Intravenous aminophylline
of oxygen. Aminophylline is a bronchodilator used as maintenance therapy. Hydration is
c. Maintain hydration status
necessary, but not overhydration. Ampicillin therapy is not considered a typical intervention in
d. Intravenous ampicillin therapy
the management of emphysema.
The practical nurse enters Mrs. Stem's room to administer the 0800 Hours insulin dose. Mrs.
Stem states , "That is not my usual dose of insulin. " How should the nurse respond to Mrs.
a. "Let me check the medication order again and I'll be back in a few minutes."
Stem?
APPLICATION QUESTION--According to the CNO compendium -medication standards---YOU
a. "Let me check the medication order again and I'll be back in a few minutes."
SHOULD ALWAYS CHECK/VALIDATE ANY MEDICATION /ORDER THAT THE PATIENT THEMSELVES
b. "I'll check with my colleague, who is right here to see if this is the right dose."
QUESTIONS. "BEST PRACTICE"
c. "I saw your insulin order about 1 hour ago and this what the physician ordered."
d. "Mrs. Stem, I know what I am doing and you should trust me, this is the correct dose."
Mrs. Soh, 65 years old, is 3 days postoperative. She is experiencing nausea and vomiting.
c. Auscultate bowel sounds
What should the nurse do?
CRITICAL THINKING QUESTION--. Yes, you will document this event, but you would manage
a. Place bed in semi-Fowler's (45 degrees)
the patient first in this case. Complete an assessment, then intervene. Bowel sounds are one
b. Document client condition
, c. Auscultate bowel sounds aspect of an assessment of peristalsis. This will help determine if the intestines are functioning,
d. Provide a glass of water and rule out bowel obstruction or other disorders.
A 19-year-old with acute asthma has come into the E.R in acute respiratory distress. His breath
rate is 44 breaths/minute. Which of the following interventions should the nurse anticipate b. Administer bronchodilator via nebulizer
first?
Critical Thinking Question: Follow Protocol ABC's First, then Nursing Process. In this case, it is
a. Obtain a complete health history an emergency, therefore we follow ABC's. The patient is experiencing an acute asthma attack,
b. Administer bronchodilator via nebulizer we will administer bronchodilator to open up the airway. Once the acute phase is over, we can
c. Provide emotional support to the client consider the other interventions.
d. Apply a cardiac monitor to the client
Which one of the following best describes the concept of Routine Precautions (formerly
Standard Precautions?
a. It is a method of infection control used only when the client tests positive for a communi- d. It is a system of generic infection control practices for all clients.
cable disease.
KNOWLEDGE QUESTION--BEST DESCRIPTION—THE OTHER RESPONSES ARE FALSE
b. It is a method of sterilization that is followed in emergency and high-risk clinical situations.
c. It is a process where soiled articles are separated from clean hospital supplies.
d. It is a system of generic infection control practices for all clients.
Mrs. Albiani, 72 years old, has pneumonia. What assessment should the nurse expect to find
during auscultation? c. Crackles
a. Wheezing KNOWLEDGE QUESTION—HYPERRESONANCE IS DUE TO EXCESSIVE AIR ACCUMULATION IN
b. Tactile fremitus LUNGS. WHEEZING IS DUE TO NARROWED AIRWAY—WHICH COULD DEVELOP LATER WITH
c. Crackles ILLNESS, SECONDARY TO THE BUILD UP OF SECRETIONS.
d. Hyperresonance
What action is best when the nurse observes that a client's drug dosage for an antihyper-
tensive medication is twice the recommended dose for that medication? d. Re-check the dosage on the physician's order sheet.
a. Take the client's vital signs before proceeding with administration CRITICAL THINKING--Always, Always recheck or verify dosages that are over the recommen-
b. Take the client's blood pressure every 1-2 hours dation, or are inaccurate.
c. Check with the client to determine how long she has been taking the medication. AS PER CNO MEDICATION STANDARDS IN COMPENDIUM
d. Re-check the dosage on the physician's order sheet.
Mr. Harrison, 29 years old, is experiencing anxiety following a diagnosis of testicular cancer.
What should the nurse do? b. Encourage him to verbalize his feelings
a. Ask him if he is concerned about not having children APPLICATION QUESTION--NURSES ARE ABLE TO LISTEN ANY EXPRESSION OF FEELINGS, IT IS
b. Encourage him to verbalize his feelings WITHIN THEIR SCOPE OF PRACTICE, THEREFORE, YOU DO NOT NEED TO REFER THIS BOUT OF
c. Suggest that he talk to his significant other. ANXIETY TO SOMEONE ELSE. A—NON-THERAPEUTIC AT THIS TIME.
d. Refer him to a testicular cancer support group.
Ben is a frail, 18-year-old client who is in the end stages of AIDS. He has open areas on his up-
per and lower extremities. He is having severe persistent pain and is due to receive morphine a. Inject the morphine in the upper abdomen using a ½ inch needle at 45 degrees.
sulfate (Morphine) 10 mg subcutaneously. Which of the following nursing interventions best
applies when the nurse prepares to administer morphine to Ben? CRITICAL THINKING QUESTION—OPEN AREAS ARE LOCATED ON UPPER EXTREMITIES,
THEREFORE, DO NOT USE THOSE SITES, 45 DEGREE ANGLE IS BEST FOR UNDERNOURISHED
a. Inject the morphine in the upper abdomen using a ½ inch needle at 45 degrees. PATIENTS. HE HAS SEVERE PAIN, THEREFORE NEEDS INTERVENTION. A CONSIDERATION FOR
b. Inject the morphine in the upper arm using a 1 inch needle at 45 degrees THE FUTURE IS POSSIBLY INVESTIGATING FOR A LONGER RELEASE/DURATION PAIN MEDICA-
c. Contact the pharmacist and ask if morphine can be absorbed subcutaneously TION.
d. Call the physician and request an alternative route for morphine
Prepare the medication using a 25-gauge, ½ inch needle
the nurse implement?
Knowledge: The nurse should NOT aspirate for blood when administering heparin because
a. Prepare the medication using a 25-gauge, ½ inch needle
this can damage surrounding tissue and cause bruising. The nurse should not massage after
b. After injecting the needle, aspirate and observe for blood
injecting heparin because this may cause bruising or bleeding. Heparin is administered in
c. After removing the needle, massage the area gently
the abdomen at least 2 inches from umbilicus-best practice.
d. Administer the medication in the client's "love handles"
a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus
The nurse is administering morning medications on a medical floor. Which medication should b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus (can
the nurse administer first? be administered within the 30-minute acceptable time frame)
c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS -pain medication is a priority,
a. Regular insulin sliding scale to an elderly client diagnosed with Type 1 diabetes mellitus but it can be administered after the sliding scale
b. Methylprednisolone, a glucocorticoid, to a client diagnosed with lupus erythematosus d. Lasix, a diuretic, to a client with hypertension- can be administered within the 30-minute
c. Morphine, a narcotic analgesic, to a client diagnosed with AIDS acceptable time frame
d. Lasix, a diuretic, to a client with hypertension Regular insulin is administered prior to meals; therefore, this medication should be admin-
istered. Critical Thinking
Which data would indicate that the antibiotic therapy has been successful for a client diag- a. The client's hematocrit is within normal range- does not indicate client response
nosed with bacterial pneumonia? b. The client is expectorating thick green sputum- symptom of pneumonia
c. The client's lung sounds are clear to ausculatation
a. The client's hematocrit is within normal range d. The client has complaints of pleuritic chest pain.— symptom of pneumonia
b. The client is expectorating thick green sputum The symptoms of pneumonia includes crackles and wheezes, rhonchi in the lung fields.
c. The client's lung sounds are clear to ausculatation Clear lungs indicate an improvement in the pneumonia and that the medication is ettective.
d. The client has complaints of pleuritic chest pain. Application
a. Ensure the client eats at least 90% of the lunch tray—insulin will not be working 4-5 hours
after being administered
The nurse is administering Humalog at 0730 to a client diagnosed with Type 1 diabetes. Which
b. Do not administer unless the breakfast tray is in the client's room
intervention should the nurse implement?
c. Check the client's blood glucose level 1 hour after receiving the insulin—glucose level
should be checked prior to administering
a. Ensure the client eats at least 90% of the lunch tray
d. Have 50% dextrose in water at the bedside for emergency use.—this is administered when
b. Do not administer unless the breakfast tray is in the client's room
a client is unconscious secondary to hypoglycemia, and should not be kept at the bedside.
c. Check the client's blood glucose level 1 hour after receiving the insulin
Orange juice or some form of simple glucose can be kept at the bedside.
d. Have 50% dextrose in water at the bedside for emergency use.
Application: The insulin peaks in 15-20 minutes after being administered; therefore, the meal
should be at the bedside prior to administering this medication
a. Wear an insect repellent on exposed skin —appropriate intervention, but if the client has
an insect bite, the repellent will not prevent anaphylaxis, therefore, not priority intervention
The client has a severe anaphylactic reaction to insect bites. What priority discharge inter-
b. Keep prescribed antihistamines on their person —used with anaphylaxis, but it takes at
vention should the nurse discuss with the client?
least 30 minutes to work, therefore not a priority medication
a. Wear an insect repellent on exposed skin c. Keep an EpiPen in the refrigerator at all times —keeping medication in the refrigerator
b. Keep prescribed antihistamines on their person does not allow it to be available to the client at all times.
c. Keep an EpiPen in the refrigerator at all times d. Wear a MedicAlert identification bracelet
d. Wear a MedicAlert identification bracelet
Application: Bracelet indicates the client is at risk for an anaphylactic reaction; therefore, this
is the priority intervention.
The client's mother contacts the clinic regarding medication administration stating, "My
d. Stop the medication and inform the physician
daughter cannot swallow this capsule. It's too large." Investigation reveals that the medication
is a capsule marked SR. The nurse should instruct the mother to: Application: SR means sustained released. These medications cannot be altered. In answers A
and B, crushing or opening the capsule is not allowed. The best response would be to inform
a. Open the capsule and mix the medication with apple sauce
the prescriber (the doctor) immediately
b. Crush the medication and administer it with a glass of liquid
, c. Call the pharmacist and request a change to a ditterent medication
d. Stop the medication and inform the physician
a. Administer the client's prescribed pain medication —should not administer pain medica-
The client calls the nursing station and requests pain medication. When the nurse enters the tion until after assessing the client's pain
room with the narcotic medication, the nurse finds the client laughing and talking with visitors. b. Assess the client's perception of pain on a 1-10 scale
Which action should the nurse administer first? c. Wait until the visitors leave to administer any medication —should assess client whether
the client has visitors or not
a. Administer the client's prescribed pain medication d. Check the MAR to see if there is a nonnarcotic medication ordered —nurse should assess
b. Assess the client's perception of pain on a 1-10 scale the client's pain first
c. Wait until the visitors leave to administer any medication
d. Check the MAR to see if there is a nonnarcotic medication ordered Application: first action is to always assess the client in pain to determine if client is having a
complication that requires medical intervention rather than PRN medication.
The client in hypovolemic shock is receiving normal saline by rapid intravenous infusion. a. The client's blood pressure is 89/48
Which assessment data would warrant immediate intervention by the nurse? b. The client's pulse oximeter reading is 95% --normal finding
c. The client's lung sounds are clear bilaterally—normal finding
a. The client's blood pressure is 89/48 d. The client's urine output is 120 mL in 3 hours—normal finding
b. The client's pulse oximeter reading is 95%
c. The client's lung sounds are clear bilaterally Application: low blood pressure reading for a client in hypovolemic shock. A B/P less than
d. The client's urine output is 120 mL in 3 hours 90/60 warrants intervention by the nurse and indicates that fluid resuscitation is not ettective.
a. Insert the needle with the bevel up at 15-degree angle in the skin
Which intervention should the nurse implement when administering a medication via the b. Prepare the medication in a 3-mL syringe using a 23-gauge 1-inch needle —wrong syringe
intradermal route? (need tuberculin syringe), wrong gauge, and wrong needle
c. Bunch the skin between the thumb and index finger of the nondominant hand---skin should
a. Insert the needle with the bevel up at 15-degree angle in the skin be spread taut, not bunched
b. Prepare the medication in a 3-mL syringe using a 23-gauge 1-inch needle d. Quickly inject the medication as to not form a wheal or bleb—medication should be
c. Bunch the skin between the thumb and index finger of the nondominant hand injected slowly to form a wheal or bleb
d. Quickly inject the medication as to not form a wheal or bleb
Knowledge: A is the correct way to administer intradermal medication
a. Stop the primary nurse and ask the nurse to step out of the room
The charge nurse is observing the primary nurse administering otic drops to a 2-year-old
b. Demonstrate inserting the otic drops by pulling up and back on the auricle—correct way
child by pulling down and back on the auricle. Which action should the charge nurse take?
for adults
a. Stop the primary nurse and ask the nurse to step out of the room c. Take no action because this is the correct way to administer the ear drops
b. Demonstrate inserting the otic drops by pulling up and back on the auricle d. Allow the nurse to administer the otic drops and then discuss the technique with the nurse
c. Take no action because this is the correct way to administer the ear drops Knowledge: This is the correct way to administer eardrops to a child younger than 3. This is
Allow the nurse to administer the otic drops and then discuss the technique with the nurse
d. done because of the short Eustachian tube of a child. The charge nurse need take no action
a. Explain that the medication must be administered because it has been drawn up —client
The nurse prepared 2 mg of morphine for a client who is complaining of pain. When the nurse has the right to refuse medication; therefore; the nurse cannot force the client to take the
enters the room the client tells the nurse, "I don't want to take a shot. I would like to have a med.
pain pill." Which action should the nurse take? b. Ask another nurse to watch the medication being wasted into the sink
c. Place the syringe in the sharps container in the client's room—legally the nurse must have
a. Explain that the medication must be administered because it has been drawn up someone witness the narcotic being wasted
b. Ask another nurse to watch the medication being wasted into the sink d. Notify the pharmacy that a narcotic was not administered to the client—does not need to
c. Place the syringe in the sharps container in the client's room— be notified
d. Notify the pharmacy that a narcotic was not administered to the client
Application: Correct procedure as per CNO medication standards of practice
a. The deltoid muscle —1-2 mL max. at this site, muscle is small
The nurse is preparing to adminster 3 mL of a medication intramuscularly to an adult client
b. The dorsogluteal muscle— not recommended because the sciatic nerve may be injured if
in the clinic. Which muscle is the best site to administer the medication?
landmarking is improper
c. The ventrogluteal muscle
, a. The deltoid muscle d. The vastus lateralis muscle— can be used, but is more painful
b. The dorsogluteal muscle
c. The ventrogluteal muscle Knowledge: site of choice is C, free of major nerves and adipose tissue to ensure medication
d. The vastus lateralis muscle goes in the muscle. It is also a larger mass of muscle.
The nurse is administering medications through a gastrostomy tube (GT). Which intervention a. Place the crushed pills in the gastrostomy tube.—Not first intervention
should the nurse implement first? b. Flush the gastrostomy with at least 30 mL of tap water
c. Use the plunger to push the medication into the GT- not first intervention
a. Place the crushed pills in the gastrostomy tube. d. Clamp the gastrostomy tube closed.— performed after medication is administered
b. Flush the gastrostomy with at least 30 mL of tap water
c. Use the plunger to push the medication into the GT Knowledge: Nurse should first flush the GT with tap water to ensure it is patent before putting
d. Clamp the gastrostomy tube closed. any medication into the GT.
a. Administer the client's medications—charge nurse cannot administer without verifying
The charge nurse is making rounds on the clients and notices the primary nurse left a
medications against MAR
medication cup with three tablets at the client's bedside. Which action should the charge
b. Remove the medication cup from the room
nurse implement?
c. Request the primary nurse come to the room—charge nurse should not correct the primary
a. Administer the client's medications nurse in front of client
b. Remove the medication cup from the room d. Leave the cup at the bedside and talk to the primary nurse
c. Request the primary nurse come to the room
Application: The nurse should take the medication cup back to the medication room and
d. Leave the cup at the bedside and talk to the primary nurse
discuss this situation with the primary nurse. Medications should never be left at the bedside.
a. The client's serum potassium level is 5.8 mEq/L
1. The client in end-stage renal disease is receiving oral Kayexalate. Which assessment data
b. The client's serum sodium level is 135 mEq/L —does not alter sodium levels (not used for
indicates the medication is not ettective?
this)
a. The client's serum potassium level is 5.8 mEq/L c. The client's serum postassium level is 4.2 mEq/L—normal level
b. The client's serum sodium level is 135 mEq/L d. The client's serum sodium level is 147 mEq/L (see above)
c. The client's serum postassium level is 4.2 mEq/L
Application: Kayexalate is a medication used to decrease potassium levels. A is an elevated
d. The client's serum sodium level is 147 mEq/L
level, therefore, medication is not ettective.
b. Intravenous aminophylline
Which of the following interventions would be a priority in the plan of care for the person with
c. Maintain hydration status
pulmonary emphysema? (Select all that apply)
Application Question: Since emphysema is a chronic disorder, the patient will be required to
a. Low flow oxygen via face mask
wear oxygen continuously, therefore nasal canula is the best way to deliver the low levels
b. Intravenous aminophylline
of oxygen. Aminophylline is a bronchodilator used as maintenance therapy. Hydration is
c. Maintain hydration status
necessary, but not overhydration. Ampicillin therapy is not considered a typical intervention in
d. Intravenous ampicillin therapy
the management of emphysema.
The practical nurse enters Mrs. Stem's room to administer the 0800 Hours insulin dose. Mrs.
Stem states , "That is not my usual dose of insulin. " How should the nurse respond to Mrs.
a. "Let me check the medication order again and I'll be back in a few minutes."
Stem?
APPLICATION QUESTION--According to the CNO compendium -medication standards---YOU
a. "Let me check the medication order again and I'll be back in a few minutes."
SHOULD ALWAYS CHECK/VALIDATE ANY MEDICATION /ORDER THAT THE PATIENT THEMSELVES
b. "I'll check with my colleague, who is right here to see if this is the right dose."
QUESTIONS. "BEST PRACTICE"
c. "I saw your insulin order about 1 hour ago and this what the physician ordered."
d. "Mrs. Stem, I know what I am doing and you should trust me, this is the correct dose."
Mrs. Soh, 65 years old, is 3 days postoperative. She is experiencing nausea and vomiting.
c. Auscultate bowel sounds
What should the nurse do?
CRITICAL THINKING QUESTION--. Yes, you will document this event, but you would manage
a. Place bed in semi-Fowler's (45 degrees)
the patient first in this case. Complete an assessment, then intervene. Bowel sounds are one
b. Document client condition
, c. Auscultate bowel sounds aspect of an assessment of peristalsis. This will help determine if the intestines are functioning,
d. Provide a glass of water and rule out bowel obstruction or other disorders.
A 19-year-old with acute asthma has come into the E.R in acute respiratory distress. His breath
rate is 44 breaths/minute. Which of the following interventions should the nurse anticipate b. Administer bronchodilator via nebulizer
first?
Critical Thinking Question: Follow Protocol ABC's First, then Nursing Process. In this case, it is
a. Obtain a complete health history an emergency, therefore we follow ABC's. The patient is experiencing an acute asthma attack,
b. Administer bronchodilator via nebulizer we will administer bronchodilator to open up the airway. Once the acute phase is over, we can
c. Provide emotional support to the client consider the other interventions.
d. Apply a cardiac monitor to the client
Which one of the following best describes the concept of Routine Precautions (formerly
Standard Precautions?
a. It is a method of infection control used only when the client tests positive for a communi- d. It is a system of generic infection control practices for all clients.
cable disease.
KNOWLEDGE QUESTION--BEST DESCRIPTION—THE OTHER RESPONSES ARE FALSE
b. It is a method of sterilization that is followed in emergency and high-risk clinical situations.
c. It is a process where soiled articles are separated from clean hospital supplies.
d. It is a system of generic infection control practices for all clients.
Mrs. Albiani, 72 years old, has pneumonia. What assessment should the nurse expect to find
during auscultation? c. Crackles
a. Wheezing KNOWLEDGE QUESTION—HYPERRESONANCE IS DUE TO EXCESSIVE AIR ACCUMULATION IN
b. Tactile fremitus LUNGS. WHEEZING IS DUE TO NARROWED AIRWAY—WHICH COULD DEVELOP LATER WITH
c. Crackles ILLNESS, SECONDARY TO THE BUILD UP OF SECRETIONS.
d. Hyperresonance
What action is best when the nurse observes that a client's drug dosage for an antihyper-
tensive medication is twice the recommended dose for that medication? d. Re-check the dosage on the physician's order sheet.
a. Take the client's vital signs before proceeding with administration CRITICAL THINKING--Always, Always recheck or verify dosages that are over the recommen-
b. Take the client's blood pressure every 1-2 hours dation, or are inaccurate.
c. Check with the client to determine how long she has been taking the medication. AS PER CNO MEDICATION STANDARDS IN COMPENDIUM
d. Re-check the dosage on the physician's order sheet.
Mr. Harrison, 29 years old, is experiencing anxiety following a diagnosis of testicular cancer.
What should the nurse do? b. Encourage him to verbalize his feelings
a. Ask him if he is concerned about not having children APPLICATION QUESTION--NURSES ARE ABLE TO LISTEN ANY EXPRESSION OF FEELINGS, IT IS
b. Encourage him to verbalize his feelings WITHIN THEIR SCOPE OF PRACTICE, THEREFORE, YOU DO NOT NEED TO REFER THIS BOUT OF
c. Suggest that he talk to his significant other. ANXIETY TO SOMEONE ELSE. A—NON-THERAPEUTIC AT THIS TIME.
d. Refer him to a testicular cancer support group.
Ben is a frail, 18-year-old client who is in the end stages of AIDS. He has open areas on his up-
per and lower extremities. He is having severe persistent pain and is due to receive morphine a. Inject the morphine in the upper abdomen using a ½ inch needle at 45 degrees.
sulfate (Morphine) 10 mg subcutaneously. Which of the following nursing interventions best
applies when the nurse prepares to administer morphine to Ben? CRITICAL THINKING QUESTION—OPEN AREAS ARE LOCATED ON UPPER EXTREMITIES,
THEREFORE, DO NOT USE THOSE SITES, 45 DEGREE ANGLE IS BEST FOR UNDERNOURISHED
a. Inject the morphine in the upper abdomen using a ½ inch needle at 45 degrees. PATIENTS. HE HAS SEVERE PAIN, THEREFORE NEEDS INTERVENTION. A CONSIDERATION FOR
b. Inject the morphine in the upper arm using a 1 inch needle at 45 degrees THE FUTURE IS POSSIBLY INVESTIGATING FOR A LONGER RELEASE/DURATION PAIN MEDICA-
c. Contact the pharmacist and ask if morphine can be absorbed subcutaneously TION.
d. Call the physician and request an alternative route for morphine
