Nokea
How can the nurse ensure correct patient identification for an unresponsive patient?
- A. By waking him up to ask him his name
- B. By identifying the patient's room number
- C. By checking the patient's wristband
- D. By asking the nursing assistant for the patient's location
Correct Answer: C
Rationale: The nurse should identify a patient by checking his wristband, which has the patient's name. The nurse should not ask the patient to confirm his name, because some patients, particularly those who are confused or have difficulty hearing, may respond by answering yes. Additionally, this patient is unresponsive. The nurse can obtain the patient's location by asking any other member of the health care staff, but should verify the patient's identity by checking the wristband. The nurse should not rely on the patient's room number alone.
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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.
What are examples of topical drugs? Select all that apply.
- A. Eyedrops
- B. Suppository
- C. Nebulized bronchodilator
- D. Nicotine patch
- E. Capsule
Correct Answer: A,B
Rationale: Topical drugs are drugs that are applied to the outer layer of the skin but not absorbed through the skin, such as eyedrops and suppositories. A nebulized bronchodilator is an inhaled medication. A nicotine patch delivers the medication transdermally; that is, it is readily absorbed from the skin. A capsule is a form of oral medication.
What action is most appropriate when administering a transdermal drug?
- A. Apply next dose to a new site
- B. Check the infusion rate
- C. Inject only the inner part of the forearm
- D. Give small volumes of doses
Correct Answer: A
Rationale: An important nursing intervention when administrating drugs through the transdermal route is to apply the next dose to a new site. It is important to check the infusion rate every 15 to 30 minutes in patients using infusion controllers or infusion pumps. When using the intradermal route, the inner part of the forearm should be used as the injection site and small volumes of doses should be administered.
What sites are appropriate for subcutaneous injection? Select all that apply.
- A. Upper arm
- B. Inner forearm
- C. Upper abdomen
- D. Gluteus maximus
- E. Upper thigh
Correct Answer: A,C,E
Rationale: The sites for subcutaneous injection are the upper arms, the upper abdomen, and the upper thighs.
What action is most appropriate when a nurse receives a STAT medication order?
- A. Insist on obtaining a written report before administering any drug
- B. Administer the drug as ordered by the physician
- C. Forgo obtaining the physician's order after the drug has been administered
- D. Document the administration of the drug only after receiving the physician's order
Correct Answer: B
Rationale: The nurse should administer the drug as instructed without a written order as it is an emergency. The nurse should, however, ensure that the physician's order is obtained after the drug has been administered. Waiting for a written order during an emergency may exacerbate the patient's condition. The nurse should complete the documentation immediately after the administration of the drug and not wait until the physician's order is received.