1. A nurse is preparing to administer an intramuscular injection to a
patient. The nurse should use which of the following sites for injection?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Subclavian
Answer: c) Vastus lateralis
Rationale: The vastus lateralis is considered a safe and effective site for
intramuscular injections, especially in adults, as it is large, well-defined,
and away from major blood vessels and nerves.
2. A patient is receiving a blood transfusion and begins to experience
shortness of breath, chest pain, and anxiety. The nurse should:
A. Continue the transfusion and monitor the patient
B. Administer oxygen and notify the healthcare provider
C. Reduce the rate of the transfusion and assess the patient
D. Check the vital signs and assess the blood bag
Answer: b) Administer oxygen and notify the healthcare provider
Rationale: These symptoms could indicate a transfusion reaction, such
as an allergic or pulmonary reaction. The nurse should stop the
transfusion and notify the healthcare provider immediately.
,3. A nurse is preparing to administer a blood transfusion to a patient.
Which of the following is the priority nursing action before starting the
transfusion?
A. Obtain a blood pressure reading
B. Confirm the patient’s identity with two identifiers
C. Check the blood bag for an expiration date
D. Verify the patient's blood type and crossmatch
Answer: b) Confirm the patient’s identity with two identifiers
Rationale: Confirming the patient’s identity with two identifiers is
essential before administering blood to ensure the correct blood
product is given to the right patient.
4. The nurse is caring for a patient receiving morphine sulfate for
postoperative pain. The nurse should monitor the patient for which of
the following side effects?
A. Tachycardia
B. Hypotension
C. Respiratory depression
D. Hyperreflexia
Answer: c) Respiratory depression
Rationale: Opioids like morphine can cause respiratory depression,
which is a serious side effect. The nurse should closely monitor the
, patient's respiratory rate and depth, especially after administration of
morphine.
5. A nurse is preparing to administer an intravenous (IV) medication.
The nurse notes that the medication is ordered as a "piggyback."
Which of the following actions should the nurse take?
A. Hang the medication on the primary IV line above the infusion site
B. Start a new IV site to administer the piggyback medication
C. Administer the medication at a slower rate than the primary infusion
D. Connect the piggyback medication directly to the patient’s central
line
Answer: a) Hang the medication on the primary IV line above the
infusion site
Rationale: The "piggyback" method involves connecting a secondary
infusion (the piggyback) to the primary IV line. It is hung higher than
the primary bag to allow for gravity-assisted flow.
6. A nurse is caring for a patient with an infected wound. What is the
priority intervention for the nurse?
A. Apply a sterile dressing
B. Administer prescribed antibiotics
C. Encourage the patient to drink fluids
D. Assess the wound for signs of improvement
Answer: b) Administer prescribed antibiotics
patient. The nurse should use which of the following sites for injection?
A. Deltoid
B. Dorsogluteal
C. Vastus lateralis
D. Subclavian
Answer: c) Vastus lateralis
Rationale: The vastus lateralis is considered a safe and effective site for
intramuscular injections, especially in adults, as it is large, well-defined,
and away from major blood vessels and nerves.
2. A patient is receiving a blood transfusion and begins to experience
shortness of breath, chest pain, and anxiety. The nurse should:
A. Continue the transfusion and monitor the patient
B. Administer oxygen and notify the healthcare provider
C. Reduce the rate of the transfusion and assess the patient
D. Check the vital signs and assess the blood bag
Answer: b) Administer oxygen and notify the healthcare provider
Rationale: These symptoms could indicate a transfusion reaction, such
as an allergic or pulmonary reaction. The nurse should stop the
transfusion and notify the healthcare provider immediately.
,3. A nurse is preparing to administer a blood transfusion to a patient.
Which of the following is the priority nursing action before starting the
transfusion?
A. Obtain a blood pressure reading
B. Confirm the patient’s identity with two identifiers
C. Check the blood bag for an expiration date
D. Verify the patient's blood type and crossmatch
Answer: b) Confirm the patient’s identity with two identifiers
Rationale: Confirming the patient’s identity with two identifiers is
essential before administering blood to ensure the correct blood
product is given to the right patient.
4. The nurse is caring for a patient receiving morphine sulfate for
postoperative pain. The nurse should monitor the patient for which of
the following side effects?
A. Tachycardia
B. Hypotension
C. Respiratory depression
D. Hyperreflexia
Answer: c) Respiratory depression
Rationale: Opioids like morphine can cause respiratory depression,
which is a serious side effect. The nurse should closely monitor the
, patient's respiratory rate and depth, especially after administration of
morphine.
5. A nurse is preparing to administer an intravenous (IV) medication.
The nurse notes that the medication is ordered as a "piggyback."
Which of the following actions should the nurse take?
A. Hang the medication on the primary IV line above the infusion site
B. Start a new IV site to administer the piggyback medication
C. Administer the medication at a slower rate than the primary infusion
D. Connect the piggyback medication directly to the patient’s central
line
Answer: a) Hang the medication on the primary IV line above the
infusion site
Rationale: The "piggyback" method involves connecting a secondary
infusion (the piggyback) to the primary IV line. It is hung higher than
the primary bag to allow for gravity-assisted flow.
6. A nurse is caring for a patient with an infected wound. What is the
priority intervention for the nurse?
A. Apply a sterile dressing
B. Administer prescribed antibiotics
C. Encourage the patient to drink fluids
D. Assess the wound for signs of improvement
Answer: b) Administer prescribed antibiotics
