FUNDAMENTALS OF NURSINGC

Medication Administration/Blood transfusion/IV therapy

1. You are to administer a medication to Mr Reyes. In addition to checking his identification bracelet, you can correctly verify his
identity by:
a. Asking the patient his name
b. Reading the patient’s name on the sign over the bed
c. Asking the patient’s roommate to verify his name
d. Asking, are you Mr. Reyes?”
2. The nurse is giving medication to an infant. What is the best way to assess the identity of the infant?
a. Ask the mother what the child’s name is
b. Look at sign above the bed that states the child’s name
c. Compare the bed number with the bed number of the care plan
d. Compare the ankle band with the name of the care plan
3. You are to administer a medication using nasogastric tube. Before giving the medication, you should:
a. Crush the enteric coated pill for mixing in a liquid
b. Flush open the tube with 60 ml of very warm water
c. Check for proper placement of the nasogastric tube
d. Take the client’s vital sign
4. The nurse manager on your unit prepared the medications for Mr Cruz. She is called to the phone and asks you to give the patient
his medications. Which is the best response to this request?
a. Give Mr Cruz the medication and record it in his chart
b. Tell the manager that you don’t have time and ask her to get someone else
c. Tell the manager that you did not pour the medication, you cannot administer it
d. Give the medication to Mr Cruz but have the manager nurse chart it
5. The nurse takes an 8 a.m. medication to the patient and properly identifies her. The patient asks the nurse to leave the medication
on the bedside table and states that she will take it with breakfast when it comes. What is best response to this request?
a. Leave the medication and return later to make sure that it was taken
b. Tell her it is against the rules, and take the medications with you
c. Tell that you cannot leave the medication but will return with it when breakfast arrives
d. Take the drug from the room and record it as refuse
6. Mrs Aquino refuses to take her noon medication, saying that she did not need it. Which of the following would be the best
response?
a. Tell her that she must take the medication because the doctor orders it
b. Tell her that you went through a lot of preparation to get her medication ready, and it is at least she can do
c. Tell her that you don’t care if she takes the medications or not
d. Tell her that you will return the medication to the cart but would like to discuss her reasons for refusing to take the
medications
7. Nurse Liza discovers that she has made a medication error. Which of the following should be her first response?
a. Record the error on the medication sheet
b. Notify the physician regarding course of action
c. Check the patient’s condition to note any possible effect of the error
d. Complete the incident report, explaining how the mistake was made
8. A client is to receive several oral medications. Which nursing instruction or action is appropriate in this situation?
a. Tell the client to take all the medications at once.
b. Advise the client to take each medication with 8 oz of water.
c. Leave the medications at the bedside for the client to take when desired.
d. State the name and action or use of each medication before administering it.
9. The client had been diagnosed to have angina pectoris. His physician prescribed nitroglycerin SL tablets for chest pain. The nurse
should teach a client to suspect that the tablets have lost their potency when:
a. Stinging sensation is experience under the tongue c. Pain is unrelieved but facial flushing is increased
b. The tablets are stored in clear plastic d. Onset of relief of chest pain is delayed
10. Which of these statements, if made the client who has a prescription for nitroglycerin tablets, would indicate a correct
understanding of the medication instruction?
a. “I should take this pill with a full glass of water”. c. “I should wait 30 minutes before taking the second pill.”
b. “I should protect this pill from lights.” d. “I should chew the pill for a faster effect.”
11. While making the client’s bed, the nurse finds a capsule of medication in the sheet. The nurse should do all of the following except:
a. administer the medication to the client c. determine what the medication the capsule contain
b. notify the physician of the miss dose d. document the incident in the nurses’ note
12. Why the intravenous method of medication administration is called the “most dangerous route of administration?
a. The vein can take only a small amount of fluid at a time
b. The vein may harden and become non-functional
c. Blood clot may become a serious problem
d. The drug is placed directly into the blood stream, and its action is immediate.
13. Mr Lopez is receiving heparin subcutaneously. Which of the following demonstrate a correct technique for this procedure?
a. Aspirate before giving and gently massage after the injection
b. Do not aspirate; massage the site for 1 minute
c. Do not aspirate before or massage after the injection
d. Massage the site of the injection; aspirate is not necessary but will do no harm
14. To give a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe.
What is the rationale for this action?
a. Adding air decreases pain caused by the injection.
b. Adding air prevents the drug from flowing back into the needle track.
c. Adding air prevents the solution from entering a blood vessel.
d. Adding air ensures that the client receives the entire dose.
15. A nurse has just administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor.
Which action is most appropriate in this situation?
a. Carefully pick up the syringe from the floor and gently recap the needle
b. Carefully pick up the syringe and dispose it in a sharp container
c. Obtained a dust pan and mop to sweep up the syringe
d. Call the housekeeping department to pick up the syringe
16. Which of the following nursing actions is most appropriate for handling chemotherapeutic agents?
a. Wear disposable gloves and protective clothing.
b. Break needles after the infusion is discontinued.
c. Disconnect the IV tubing with gloved hands.
d. Throw IV tubing in the trash after the infusion is discontinued.
17. A nurse teaches a client about the use of respiratory inhaler. Which action by the client indicates a need for further teaching?
A. Removes the cap and shakes the inhaler well before use.
B. Presses the canister down with the finger as he breaths in
C. Inhales the mist and quickly exhales
D. Waits 1 to 2 min between puffs if more than 1 puff has been prescribed
18. To minimize fungal infections in patient on inhaled steroids, he should be taught to:
a. Wash the mouthpiece frequently c. Avoid sugar
b. Limit spicy foods d. Rinse mouth after inhaling drug
19. The nurse prepares an adult client for instillation of ear drops. The nurse should use which of the following methods to administer
the ear drops?
a. Cool the solution for better absorption. Drop the medication directly into the auditory canal.
b. Warm the solution. Flush the medication rapidly into the ear.
c. Warm the solution. Drop the medication along the side of the ear canal.
d. Warm the solution to 40 degrees centigrade. Drop the medication slowly into the ear canal.
20. Following instructions on self-administration of insulin, the patient should be able to demonstrate his knowledge that tissue
hypertrophy (lipodystropy) is prevented by
a. using the same injection site c. injecting the insulin into the adipose tissue
b. administering room temperature insulin d. chilling the insulin before injection
21. You are to administer a medication using nasogastric tube. Before giving the medication, you should:
a. Crush the enteric coated pill for mixing in a liquid c. Check for proper placement of the nasogastric tube
b. Flush open the tube with 60 ml of very warm water d. Take the client’s vital sign
22. A client comes to the clinic for diagnostic allergy testing. Why is intradermal injection used for such testing?
a. Intradermal injection is less painful. c. Intradermal drugs diffuse more rapidly.
b. Intradermal drugs are easier to administer. d. Intradermal drugs diffuse more slowly.
23. Intramuscular injection for an infant should be done in what muscle?
a. Vastus lateralis c. Gluteus minimus muscle
b. Gluteus maximus muscle d. Deltoid area
24. All of the following nursing interventions are correct when using Z tract method of drug injection except?
a. Prepare the injection site with alcohol c. Aspirate for blood before injection
b. Use a needle that is at least 1 inch long d. Massage the site after injection
25. The best way to instill eye drops is to:
a. Instruct the patient to look upward, and drop the medication into the center of the lower lid.
b. Instruct the patient to look ahead, and drop the medication into the center of the lower lid
c. Drop the medication into the lower cantus regardless of position
d. Drop the medication into the center of the cantus regardless of the position
26. A client will receive an IM injection. The nurse decided to give it in the dorsogluteal area. The position is:
a. Sim’s c. Prone with toes pointing inward
b. Prone d. Standing
27. A client has serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
a. repeat glycohemoglobin in 24 hours c. humulin N 20 units IV push
b. document accuchecks, intake and output every 4 hours d. IV fluids of 0.9% normal saline at 125 ml per hour
28. A client receiving an anticoagulant for a pulmonary embolism. The drug that is contraindicated for client receiving anticoagulant is:
a. Ferrous sulfate c. Isoxsuprine (vasodiland]
b. Acetylsalycylic acid d. Thorazine
29. Before starting blood transfusion, the nurse should prepare what solution?
a. 0.9%NaCl c. PLR
b. D5LR d. D10W
30. An elderly client is on bed rest. While administering an intramuscular injection, the most important action to prevent introduction
of the medication into the venous system is which of the following?
a. injection the medication slowly to allow for slow absorption
b. insert the needle at a 45 degree angle where there are fewer blood vessel
c. use Z tract method of injection
d. aspirate the drug after the insertion
31. A client is to receive an IM injection of penicillin. In preparing the medication, the best nursing approach is to:
a. Use a sterile syringe and needle
b. provide for the safety of the client by using the proper equipment and aseptic technique
c. Prepare the skin site with an antiseptic swab, moving from the center of the site outward
d. prevent contamination of the needle by not allowing it to touch any contaminated
surfaces.
32. During the administration of the medication, the priority nursing assessment is which of the following?
a. help the client swallow the medication c. keep all prepared medication on site
b. Identify the client d. assess the client for any untoward effect after 1 hour
33. To decrease the incidence of edema at the injection site when heparin sodium is administered, the nurse should do which of these
actions?
a. Gently massage the injection site after administering heparin.
b. Use the Z-track technique for administering heparin.
c. Rotate the site for injecting heparin.
d. Aspirate for blood before injecting heparin
34. A client is schedule to receive his insulin at 8:00 A.M. In preparing and administering medication to him, which of the following is
the best action?
a. read the label three times c. administer the correct mediation to the right client
b. check the client’s identification bracelet d. check the dosage prescribed
35. The nurse to administer an I.M. injection into a client’s left vastus lateralis muscle, how should the nurse position the client?
a. Lying supine c. Lying on the left side
b. Lying on the stomach d. Lying on the right side
36. An adult client has central line placed for IV fluids. When the nurse enters the room, the IV bottle is empty, the IV line is full of air,
and the client is dyspneic. What is the best nursing action?
a. Notify the MD and administer oxygen via nasal cannula immediately
b. Hang another IV bag as soon as possible, and remove the air from the IV catheter
c. Clamp the tubing and place the client on the left side with the head down
d. Begin CPR and call the code team
37. While performing rounds, a nurse finds a client is receiving the wrong I.V. solution, the nurse’s initial response should be to:
a. Remove the I.V. catheter and call a physician.
b. Write up an incident report describing the mistake.
c. Slow the I.V. flow rate and hang the appropriate solution.
d. Wait until the next bottle is due and then change to the proper solution.
38. When preparing for piggyback medication for a client, the nurse is aware that it is essential to:
a. Use strict sterile technique c. Use exactly 100 ml of fluid to mix the medication
b. Rotate the bag after adding the medication d. Change the needle just before adding the medication
39. The client is receiving 5% dextrose in water t a slower rate. The nurse should be aware that the longest period of time that one
bottle can be infused without producing untoward effects is:
a. 6 hours b. 12 hours c. 18 hours d. 24 hours
40. The nurse is aware that infiltration of a client’s IV is most likely caused by:
a. Excessive height of the IV solution c. Lack of sepsis during catheter insertion
b. Failure to adequately secure the catheter d. Infusion of chemically irritating medication
41 .A client has an IV infusion, If the IV infusion infiltrates, the nurse should first:
a. Elevate the IV site c. Attempt to flush the tube
b. Discontinue the infusion d. Apply warm, moist soaks
42. Client is for blood transfusion. After 30 minutes of transfusion, the client complains of itching and headache. Her blood pressure is
80/64. The first nursing action should be to:
a. Notify the physician c. Notify the laboratory
b. Obtain a urine specimen. d. Stop the infusion of blood
43. While observing a client throughout a blood transfusion, the nurse should be alert to which possible sign of a hemolytic reaction?
a. Urticaria b. Polyuria c. Flank pain d. hypothermia
44. A client is for blood transfusion. Two RN checked the blood bag. Just before beginning the transfusion, the nurse assesses which of
the following:
a. Vital sign b. Latest hematocrit level c. Skin color d. Urine output
45. Ten minutes after blood transfusion, the patient complained of headache, chills and backache. What is the immediate action of the
nurse?
a. Slow the rate of transfusion. c. Return the blood back to the laboratory.
b. Replace the line with NSS solution. d. Administer ASA as ordered.
46. During blood transfusion, a client develops chills and headaches. The nurse best action is to:
a. lightly cover the client c. stop the transfusion immediately
b. call the physician stat d. slow the blood flow and keep vein open
47. Which intervention has the highest priority when a nurse is caring for a client receiving a blood transfusion?
a. Document the blood administration in the client care record
b. Inform the client that the transfusion usually takes 1 ½ to 2 hours
c. Instruct the client to notify the nurse if itching, swelling, or dyspnea occurs
d. Assess the client’s vital sign after the transfusion is completed
48. When administering blood, it is important that the nurse to:
a. Administer each unit within a 6 hour period
b. Use a volume control infusion pump to administer the blood
c. Run the blood at a slower rate during the first 5 to 10 minutes
d. Draw the blood sample from the client immediately after each unit
49. Most medication error occurs when the nurse:
a. Falls to follow routine procedure c. Is caring too many clients
b. Is responsible for administering numerous medications d. Is administering unfamiliar medication.
50. A telephone order involves:
a. A physician giving any health care worker an order via the phone
b. No liability on the part of the nurse taking the phone order
c. Use only in acute emergency
d. Clarification, accuracy, and verification.