Nokea
What action is most important to minimize tissue damage when administering subcutaneous heparin?
- A. Insert the needle at the appropriate angle
- B. Select the needle length based on the patient's weight
- C. Ensure that there is no hair on the injection site
- D. Rotate the injection site regularly
Correct Answer: D
Rationale: The nurse should rotate the injection sites to minimize the damage caused to the tissue. Inserting the needle at the proper angle and selecting the needle length based on the patient's weight will not significantly help in minimizing tissue damage if the same site is repeatedly injected. It is not necessary to avoid injection sites that have hair as long as the drug is administered in the upper arms, the upper abdomen, and the upper back.
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What is the most appropriate response when a patient says, 'This doesn't look like my usual pill'?
- A. This is the same pill your doctor has been ordering.'
- B. It must be from a different manufacturer.'
- C. It looks different? Are you sure?'
- D. Let me double check with your doctor and the order.'
Correct Answer: D
Rationale: If the patient makes any statement about the drug, the nurse needs to hold the drug and investigate the patient's statement, double checking the chart and the order and obtaining clarification and/or confirmation from the prescriber. It may be that the dosage or manufacturer has changed and that is what makes the pill look different. It is always important to err on the side of caution. Telling the patient that the pill is the same or that it is from a different manufacturer may be true, but the nurse needs to confirm that before giving it to the patient. Repeating the patient's statement and then asking him if he is sure is inappropriate because it implies that the patient is incorrect.
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.
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 actions are appropriate when administering an intramuscular injection? Select all that apply.
- A. Always wear gloves
- B. Cleanse skin at injection site
- C. Place pressure on the area after removing the needle
- D. Recap the needle before disposal
- E. Aspirate after inserting the needle
Correct Answer: A,B,C,E
Rationale: When administering an intramuscular injection, the nurse should always wear gloves, cleanse the skin at the injection site prior to administration, aspirate for 5 to 10 seconds after inserting the needle, apply pressure to the area after removing the needle, and never recap the needle.
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.