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What site is most appropriate for an IM injection in an 18-month-old toddler?
- A. Dorsogluteal site
- B. Deltoid muscle
- C. Vastus lateralis
- D. Ventrogluteal site
Correct Answer: C
Rationale: The vastus lateralis site is frequently used for infants and small children because it is more developed than the other intramuscular sites such as the dorsogluteal and deltoid muscle. Ventrogluteal sites may be used in children who have been ambulating for more than 2 years.
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The five+ 1 rights of drug administration include which of the following? Select all that apply.
- A. Right documentation
- B. Right patient
- C. Right route
- D. Right drug
- E. Right prescriber
Correct Answer: A,B,C,D
Rationale: The five+ 1 rights of drug administration include: right patient, right drug, right dose, right route, right time, and right documentation.
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.
What types of orders for drug therapy might the nurse expect to find in a client's medical record? Select all that apply.
- A. Standing order
- B. STAT order
- C. Single order
- D. Alternate order
- E. PRN order
Correct Answer: A,B,C,E
Rationale: Common orders given by health care providers for drug therapy include the standing order, the single order, the PRN order, and the STAT order.
What action is most appropriate immediately after administering an opioid drug?
- A. Monitoring the vital signs of the patient
- B. Documenting administration of the drug
- C. Informing the patient about the type of drug
- D. Updating the physician regarding the patient's condition
Correct Answer: B
Rationale: After administration of any drug, the nurse should immediately document the administration. After the documentation is complete, the nurse can record the patient's vital signs. The patient needs to be informed about the drug before the administration. The physician need not be immediately informed, unless the client develops severe adverse reactions.
How many times should the student compare the drug label with the MAR when preparing an oral drug for administration?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: B
Rationale: The proper procedure is to compare the drug label with the MAR three times: (a) when the drug is taken from its storage area, (b) immediately before removing the drug from the container, and (c) before administering the drug to the patient.