Nokea
A nurse's responsibility when a drug is prescribed for a client includes which of the following? Select all that apply.
- A. Administering the drug to the client
- B. Monitoring for therapeutic response
- C. Checking for drug?drug interactions
- D. Reporting adverse reactions
- E. Teaching the client information needed to administer drugs safely at home
Correct Answer: A,B,D,E
Rationale: When a drug is prescribed to a client, the nurse is responsible for the administration of the drug, monitoring for therapeutic effects, reporting adverse drug reactions, and teaching the client information needed to administer the drug safely at home. A pharmacist checks for drug?drug interactions prior to dispensing a drug for administration.
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When administering a prescribed drug, which actions are completely inappropriate? Select all that apply.
- A. Charting immediately on the MAR after drug administration
- B. Removing a drug from an unlabeled container
- C. Giving a drug that someone else prepared
- D. Crushing tablets or opening capsules without consulting a pharmacist
- E. Removing the drug's unit dose wrapper at the client's bedside
Correct Answer: B,C,D
Rationale: The nurse should always record immediately on the MAR after drug administration. The nurse should never remove a drug from an unlabeled container, give a drug that someone else prepared, or crush tablets or open capsules without consulting a pharmacist. The drug's unit dose wrapper should remain on until the nurse arrives at the client's bedside.
At what angle should the nurse insert the needle for an intradermal injection?
- A. 15 degrees
- B. 30 degrees
- C. 45 degrees
- D. 90 degrees
Correct Answer: A
Rationale: When giving an intradermal injection, the needle is inserted bevel up at a 15-degree angle. The nurse would insert the needle at a 90-degree angle for an intramuscular injection or for a patient who is obese and requires a subcutaneous injection. Typically a subcutaneous injection is given at a 45-degree angle.
What action is most appropriate when a nurse cannot read a healthcare provider's handwriting on a medication order?
- A. The nurse should question the order with the primary health care provider
- B. The nurse should try to interpret the handwriting
- C. The nurse should confirm the order with a nearby health care provider
- D. The nurse should obtain a verbal order
Correct Answer: A
Rationale: Any order that is unclear, particularly due to illegible handwriting, should be questioned. The nurse should not try to interpret the handwriting as it may lead to a misinterpretation. The nurse should also not confirm the order with any other physician who is nearby. Administering drugs based on verbal orders is permissible only during emergencies.
What gauge needles are appropriate for intradermal injections? Select all that apply.
- A. 26 gauge
- B. 28 gauge
- C. 29 gauge
- D. 25 gauge
- E. 27 gauge
Correct Answer: A,D,E
Rationale: A 1-mL syringe with a 25- to 27-gauge needle that is 1/4 to 5/8 inches long is best suited for intradermal injections.
When a primary health care provider phones in a medication order, what should the nurse do? Select all that apply.
- A. Write down the order
- B. Record the order as soon as the MAR is retrieved
- C. Repeat back the information exactly as written
- D. Clarify any unclear information
- E. Obtain verbal confirmation that the information is correct
Correct Answer: A,C,D,E
Rationale: If a verbal order is given over the telephone, the nurse writes down the order immediately, repeats back the information exactly as written, and then asks for a verbal confirmation that it is correct. Any order that is unclear should be questioned and clarified.