Which of the following nursing actions should be preformed initially when performing a bloodglucose test on a type 1 diabetic?Wearing clean gloves to minimize the risk of contaminationAssessing the patient’s skin for possible puncture sitesHaving the patient wash his or her hands in warm, soapy waterDetermining the patient’s preferred puncture siteThe nurse is preparing medication to be administered via a subcutaneous injection. The patient is ofaverage height and weight. Which of the following needles would be the appropriate choice for such aninjection?20 gauge, 1 inch22 gauge, 1 inch25 gauge, 3/8 inch27 gauge, Â½ inchWhen providing management for a patient with an NG tube attached to low suction, the nurse shouldperform which of the following when preparing to auscultate for bowel sounds?Initially palpate the abdomen.Turn the suction off while listening.Position the patient in a supine position.Measure the gastric output presently availableThe initial step when preparing to administer a prescribed medication to a patient using a medicationdispensing system is to:Perform effective hand hygiene before handling the medication.Review the medication administration record (MAR) for all needed information.Provide the patient with educational information regarding the new medication.Review all of the nursing considerations appropriate for this particular prescribed medicationThe nurse is preparing to apply a topical oil-based medication to a patient’s forearms. To best minimizethe risk of contamination during the application, the nurse should:Encourage the patient to self-apply the medication.Wear treatment gloves during the entire application process.Change gloves between prepping the skin and applying the medication.Perform effective hand hygiene before and after the application processWhen preparing to administer a new medication, the patient informs the nurse that he is allergic to thedrug. To best address this situation, the nurse should initially:Notify the physician.Withhold the medication.Check the patient for an allergy ID band.Review the medical record for allergies.The nurse is preparing to apply an estrogen patch to a patient who will be discharged with a prescriptionfor the medication. To ensure effective self-application of the medication patch, the nurse should:Assess the patient’s understanding of the purpose of the medication.Determine the patient’s physical fine grasp ability.Assess the patient’s skin for appropriate application sites.Determine the patient’s ability to recognize the medication’s possible side effectsAfter requesting a narcotic pain medication, the patient refuses it when the nurse prepares to administerthe injection. The nurse best addresses this situation by:Offering to provide the patient with the medication in its oral form.Notifying the physician that the patient no longer requires pain medication.Having another registered nurse witness the discarding of the drug according to facility policy.Providing the patient with an explanation regarding the need to manage pain effectivelyWhile reviewing a newly written medication order, the nurse notes that the frequency of administrationhas been omitted from the prescription. The nurse best addresses this situation by:Immediately calling the prescriber to complete the medication prescription.Referring to a current drug book for the most commonly prescribed frequency.Calling the pharmacy to determine the most appropriate frequency for the prescribed dose.Asking another registered nurse who is familiar with the prescriber to identify the frequency usuallyorderedTo best minimize the patient’s risk for injury when administering a medication to a patient using amedication dispensing system, the nurse should:Assess the patient’s ability to swallow oral medications without difficulty.Question the patient regarding experiences with this or similar medications.Compare the drug’s label with the MAR three times.Evaluate the patient’s understanding of the safety issues related to the particular drugAn elderly patient is to be discharged with an antiinflammatory medication that is to be taken twicedaily. When reviewing the prescription, the nurse recognizes that the patient is at the greatest risk forinjury when it is noted that the prescription:Does not include the patient’s full name.Indicates an unusually low dose of the medication.Orders the medication to be taken more frequently than usual.Fails to indicate the exact times the medication should be takenTo best minimize the risk of coming into contact with gastric contents during the removal of a nasogastrictube, the nurse should:Protect the patient’s chest with an absorbent towel.Instruct the patient to swallow just before the removal.Flush the tubing with 30 ml of air using a catheter-tipped syringe.Place the patient in a high-Fowler’s position for the removal processIt is 2100 when the nurse realizes that a patient did not receive the 0900 dose of a bid medication. Thenurse’s initial reaction to the medication error should be to:Notify the physician.Administer the missed dose.Explain the situation to the patient.Inform the responsible nurse of the errorWhich of the following interventions can the nurse delegate to ancillary staff regarding the insertion of anasogastric tube in an elderly patient?Positioning the patient in a high-Fowler’s positionAssessing the patient’s abdomen for bowel soundsDetermining any history of unexplained nosebleedsEducating the patient regarding the need for the interventionThe nurse is preparing a scheduled medication for a patient using the unit’s medication dispensingsystem. To best ensure both patient and staff safety, the nurse should:Never share the personal dispenser log-in code.Have another registered nurse check the mathematical calculations used.Review a current drug book for prescribed dosing information.Use two different mathematical formulas to arrive at the amountThe nurse is preparing to administer insulin to a patient. Which of the following actions will best ensurethe patient’s safety?Determining the patient’s current blood glucose levelPreparing the injection site with an antibacterial cleansingDonning treatment gloves when administering the medicationWiping the seal of the vial with alcohol before withdrawing the medicationWhen preparing an injection with medication contained in an ampule, the nurse can best minimize therisk of infection for the patient by:Performing effective hand hygiene before initiating the preparation process.Preparing the medication for administration in the patient’s room.Donning treatment gloves during the preparing of the medication.Preserving the sterility of the needle during the preparation process.The nurse realizes that a suspected positive TB reaction between 48 and 72 hours at the injection sitewould include a:Bleb the size of a mosquito bite.Bruised area greater than 10 mm in size.Hard, raised area 15 mm in diameter.Red, itchy rash area 5 mm or greater in size.Which of the following nursing actions is appropriate when assessing 50 ml of residual stomach contentfor pH in preparation for an enteral feeding?Return it to the stomach via the feeding tube.Dispose of it down the bathroom commode.Discard it as a liquid biohazard waste material.Return half of the volume to the stomach and discard the restThe nurse has provided a patient with a prn oral analgesic that may be repeated as needed every 6 to 8hours. The most appropriate follow-up action to ensure appropriate pain management is to:Re-assess the patient’s pain in 30 to 40 minutes.Document the patient’s request for pain medication.Provide the patient with the pain medication again in 6 hours.Include the patient’s pain history in the end-of-shift nursing reportThe patient refuses the scheduled dose of an antibiotic claiming that the medication causes him to benauseous. To best minimize the patient’s risk of injury, the nurse should:Provide the patient with a detailed explanation as to why the medication is needed.Notify the prescriber of the patient’s reason for refusing the medication.Offer to administer the medication with the patient’s favorite snack food.Call the physician to get a different antibiotic prescription.When preparing an injection with medication contained in an ampule, the nurse can best minimize therisk of introducing glass particles into the syringe by:Minimizing the force used to snap the neck of the ampule.Using gauze to cover the top of the ampule when snapping it.Using a filter needle when withdrawing the medication into the syringe.Allowing the medication to settle after the ampule has been snapped open.The initial step when preparing to administer a newly ordered medication to a patient is to:Perform effective hand hygiene before handling the medication.Compare the written order with the medication administration record (MAR).Provide the patient with information regarding the new medication.Review the nursing considerations appropriate for the prescribed medicationThe nurse is instilling a medication into the ear of an elderly patient with an ear infection. To bestmaximize the distribution of the medication after instillation, the nurse should instruct the patient to:Have a family member instill the medication.Avoid contaminating the medication’s applicator tip.Instill the medication at the time the physician ordered.Instill the medication after gently pulling the ear up and backThe nurse is preparing to remove a nasogastric tube from a postoperative patient. Which of the followingactions should the nurse perform initially to minimize patient anxiety concerning the intervention?Administer a mild sedative prescribed by the patient’s physician.Ask the patient’s husband to emotionally support her during the removal.Provide reassurance that the removal will be less distressing than the insertion.Instruct the patient to take deep, calming breaths while revisiting a pleasant memory.To best minimize the patient’s risk of injury when delivering a medication via intramuscular injection, thenurse realizes that the:Patient should be instructed to relax the muscle at the insertion point.Needle should be quickly inserted into the muscle at a 90-degree angle.Plunger should be pulled back after the needle is inserted into the muscle.Skin over the insertion site should be held taut during the needle insertion.To best minimize the patient’s risk for injury when administering a medication, the nurse should:Never leave medication at the patient’s bedside to be taken later.Question the patient regarding experiences with this medication.Assess the patient’s ability to swallow oral medications without difficulty.Evaluate the patient’s understanding of the safety issues relatedto the drugTo assess patency of enteral nutrition tubing being used for a gravity controlled feedings, the nurse mustinitially:Elevate the head of the patient’s bed to at least 30 degrees.Raise the filled syringe up to 18 inches above the insertion point.Irrigate the tubing with 30 ml of room-temperature normal saline.Monitor the amount of intake the patient tolerates in a 8-hour period.When preparing an injection that contains both short- and intermediate-acting insulins, the nurse willmost effectively ensure the effectiveness of this insulin injection by initially:Inserting air into the cloudy insulin.Warming the vials to room temperature.Withdrawing the prescribed amount of clear insulin.Rotating the vials for at least 1 minute.The nurse is preparing to apply a nitroglycerin patch on a patient with a history of angina. To bestminimize the risk of contact with the medication, the nurse should:Wash hands immediately upon completion of the application.Handle only the outer edges of the unwrapped patch.Wear treatment gloves during the application.Fold the patch in on itself after removal.When preparing to administer medication via the subcutaneous route, the nurse should avoid which ofthe following sites?Lower abdomen of an obese patientScapular area of a patient who is on bedrestRight deltoid of a high school softball pitcherLateral aspect of the thigh of a patient with a venous clotWhich of the following nursing actions is best suited to evaluate the external placement of an NG tubewhen the patient asks, "Is this tube still where it is supposed to be?"Assessing the abdomen for rigidity and/or distentionMeasuring the amount of gastric output in the collection unitChecking the pen mark on the tube in relationship to the nostrilAuscultating the abdomen for the presence of normal bowel soundsThe nurse is instilling a medication into the eye of a patient who recently underwent eye surgery. Tobest maximize the distribution of the medication after instillation, the nurse should instruct the patientto:Blink the eye 10 times.Keep the eye closed for 2 minutes.Apply pressure on the nasolacrimal duct for 1 minute.Keep the head hyperextended for 3 additional minutes
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