Answers With Updated Solutions
You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read
a health care provider's order for one of your patient's medications. You have heard from more experienced
nurses that this health care provider does not like to be called, and you know that another of the health care
provider's patients is very unstable. What is the most appropriate next step for you to take?
1. Call the health care provider to clarify the order
2. Talk with your preceptor to help you interpret the order
3. Refer to a medication manual before giving the medication
4. Use your best judgment and critical thinking and administer the dose you think the health care provider
ordered ANS 1. Call the health care provider to clarify the order
A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for
medication administration for this child?
1. A medication cup
2. A teaspoon
3. A 5-mL syringe
4. An oral-dosing syringe ANS 4. An oral-dosing syringe
What statement made by a 4-year-old patient's mother indicates that she understands how to administer her
son's eardrops?
1. "To straighten his ear canal, I need to pull the outside part of his ear down and back."
,2. "I need to straighten his ear canal before administering the medication by pulling his ear upward and
outward."
3. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him
the eardrops."
4. "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at
least 10 minutes." ANS 2. "I need to straighten his ear canal before administering the medication by
pulling his ear upward and outward."
A health care provider ordered enalapril (Vasotec) 2 mg IV push for a patient with hypertension. The pharmacy
sent vials marked 1.25 mg enalapril/mL. How many mL does the nurse administer? ___ mL ANS 1.6 mL
A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and
depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes
that the patient has three health care providers who have ordered a total of 13 medications. What is the most
appropriate action for the nurse to take next?
1. Give the medications after identifying the patient using two patient identifiers
2. Provide medication education to the patient to help with adherence to the medical plan
3. Review the list of medications with the health care providers to ensure that the patient needs all 13
medications
4. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the
hospital ANS 3. Review the list of medications with the health care providers to ensure that the patient
needs all 13 medications
The nurse is administering an intravenous (IV) push medication to a patient who has a compatible IV fluid
running through intravenous tubing. Place the following steps in the appropriate order.
1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or
medication reference manual. Use watch to time administration.
,2. Select injection port of intravenous (IV) tubing closest to patient. Whenever possible, injection port should
accept a needleless syringe. Use IV filter if required by medication reference or agency policy.
3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.
4. Connect syringe to port of intravenous (IV) line. Insert needleless tip or small-gauge needle of syringe
containing prepared drug through center of injection port.
5. Clean injection port with antiseptic swab. Allow to dry.
6. Occlude intravenous (I ANS 2, 5, 4, 6, 1, 3
A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was
yesterday. What is the appropriate action for the nursing student to take next?
1. Ask the nursing professor for advice
2. Return the medication to pharmacy and get another tablet
3. Call the health care provider after discussing this situation with the charge nurse
4. Administer the medication since medications are good for 30 days after their expiration date ANS 2.
Return the medication to pharmacy and get another tablet
A nursing student is administering medications to a patient through a gastric tube (G-tube). Which of the
following actions taken by the nursing student requires the nursing instructor to intervene?
1. The nursing student places all the patient's medications in different medicine cups.
2. The nursing student evaluates each medication and holds the tube feeding before administering a medication
that needs to be administered on an empty stomach.
3. The nursing student flushes the tube with 30 mL of water between each medication.
, 4. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before
administering it. ANS 4. The nursing student crushes a nifedipine extended-release tablet and mixes it with
water before administering it.
A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away
because she is not going to take it. What is the nurse's next action?
1. Ask the patient's reason for refusal
2. Consult with the patient's parents for advice
3. Take the medication away and chart the patient's refusal
4. Tell the patient that her health care provider knows what is best for her ANS 1. Ask the patient's reason
for refusal
After receiving an intramuscular (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.)
1. Assess the injection site
2. Administer an oral medication for pain
3. Notify the patient's health care provider of assessment findings
4. Document assessment findings and related interventions in the patient's medical record
5. This is a normal finding so nothing needs to be done
6. Apply ice to the site for relief of burning pain ANS 1. Assess the injection site
3. Notify the patient's health care provider of assessment findings