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Medication Administration and the Six Rights

• To ensure the "right patient" receives medication, the nurse must verify the patient's name and date of birth, using two patient identifiers.
• Room numbers are not reliable identifiers.
• To ensure the "right dose" of medication is administered, double-check calculations with another nurse.
• High-risk medications require independent double-checking to prevent dosing errors.
• When administering a sublingual medication, instruct the patient to place the medication under their tongue and let it dissolve.
• Sublingual medications are absorbed through the mucous membranes under the tongue for rapid systemic effect.
• Administer the medication as prescribed to ensure the "right route" of medication administration is followed.
• The route of administration is determined by the prescriber based on the drug's pharmacokinetics and the patient's condition.
• When administering a topical medication, apply the medication to clean, dry skin.
• Topical medications are most effective when applied to clean, dry skin for proper absoprtion.

Injection Techniques and Landmarks

• The ventrogluteal site is the most appropriate site for intramuscular (IM) injections in adults because it has fewer blood vessels and nerves, reducing the risk of complications.
• When administering a subcutaneous (SubQ) injection, a 5/8 inch, 25 gauge needle size is most appropriate.
• SubQ injections require a shorter needle (5/8 inch) and smaller gauge (25-30) to ensure the medication is deposited in the subcutaneous tissue.
• When administering an intradermal (ID) injection, the angle should be 10-15 degrees.
• ID injections are administered at a shallow angle to ensure the medication is deposited in the dermis.
• The vastus lateralis is the preferred site for IM injections in infants because it is well-developed and free of major blood vessels and nerves.
• The purpose of the Z-track IM injection technique is to prevent leakage into subcutaneous tissue, which can cause irritation.

Medication Administration and Patient Safety

• Clarify the order with the prescriber if a medication order is unclear, as clarification ensures patient safety.
• Monitoring peak and trough levels evaluates the medication's effectiveness and toxicity, such as with antibiotics.
• When administering a medication via a nebulizer, instruct the patient to breathe normally through the mouthpiece, allowing proper delivery to the lungs.
• Sterile technique should be used when administering ear irrigations to prevent infection.
• When administering a medication to a patient with dysphagia, the nasogastric tube route is most appropriate, ensuring safe delivery.

Pharmacology and Physiology

• Sublingual nitroglycerin tablets are administered because this route avoids first-pass metabolism, bypassing the liver for rapid systemic effects.
• Vaccines primarily act on the lymphatic system, stimulating the immune system.
• Alanine aminotransferase (ALT) should be monitored when administering a medication metabolized by the liver; elevated levels may suggest liver damage.
• When administering a medication excreted by the kidneys, serum creatinine should be monitored, as elevated levels may indicate impaired renal excretion.
• Medications that cause vasodilation are expected to increase peripheral blood flow and reduce blood pressure.

Patient Education and Communication

• Instruct the patient to hold their breath for 10 seconds after inhaling when teaching about the use of a metered-dose inhaler (MDI), allowing maximum effectiveness.
• Remove the old patch before applying a new one when teaching a patient about the use of a transdermal patch.
• Leaving an old patch on can lead to overdose or skin irritation.
• Apply pressure to the inner canthus after instilling the drops when teaching a patient about the use of eye drops to prevent systemic absorption of the medication.
• When teaching a patient about the use of a buccal medication, instruct them to place the medication between their cheek and gum, where it's absorbed through the mucous membranes.
• The instruction to apply the medication to clean, dry skin is appropriate when teaching a patient about the use of a topical corticosteroid.
• Topical corticosteroids are most effective when applied to clean, dry skin.

Special Considerations

• Elderly patients are at increased risk for adverse drug reactions due to age-related changes in metabolism, absorption, and excretion.
• Pediatric patients are at increased risk for medication errors due to weight-based dosing, where miscalculations can lead to errors.
• Pregnant patients are at increased risk for teratogenic effects, as medications can cross the placenta and harm the developing fetus.
• Medications can be excreted in breast milk, thus a nurse should consider this when administering medications to a breastfeeding patient, as medications taken by the mother can pass into breast milk and affect the infant.
• Patients with renal impairment may require a longer dosing interval, as renal impairment reduces the excretion of medications, increasing the risk of toxicity; adjustments in dosing intervals may be necessary.

Physiological Effects of Immobility

• Deep vein thrombosis (DVT) is the complication an immobile client is at greatest risk for due to venous stasis.
• Pneumonia is the most common respiratory complication in immobile clients due to stasis of secretions.
• A warm, reddened calf indicates a potential complication of immobility, which may indicate DVT.
• Repositioning every 2 hours is the most effective intervention in preventing pressure ulcers in an immobile client because frequent repositioning relieves pressure and prevents skin breakdown.
• Adequate hydration is an important intervention to prevent constipation in immobile clients.

Range of Motion (ROM) Exercises

• "I will move my joints myself." indicates understanding of active ROM exercises, which are performed by the client independently.
• Move the client's joints through their full range when performing passive ROM exercises for a client, as passive ROM exercises are performed by the nurse moving the client's joints.
• A joint movement included in ROM exercises is flexion, a common motion.

Body Mechanics

• "Bend at the knees and keep your back straight." is the correct instruction about proper body mechanics, involving bending at the knees and keeping the back straight to prevent injury.
• Locking the wheelchair brakes is the most important action when transferring a client from the bed to a wheelchair, ensuring the wheelchair does not move during the transfer.

Assistive Devices

• "Hold the cane on the unaffected side." is the correct instruction when teaching a client how to use a cane, as the cane is held on the unaffected side to provide support and balance.
• "Lift the walker and move it forward." is the correct instruction when teaching a client how to use a walker, as walkers should be lifted and moved forward to ensure stability.

Client/Caregiver Education

• "I will perform ROM exercises daily." statement by the caregiver indicates understanding, because ROM exercises should be performed daily to maintain joint mobility.
• "Bend at the knees and keep your back straight." is the correct instruction when teaching a client about proper body mechanics, as body mechanics involve bending at the knees and keeping the back straight to prevent injury.
• A red, non-blanchable area over a client's sacrum is a Stage 1 pressure ulcer, presenting as intact, non-blanchable redness without skin breakdown.
• A drop in blood pressure when standing indicates a risk for developing orthostatic hypotension in an immobile client, which is a drop in BP ≥20 mmHg systolic or ≥10 mmHg diastolic when moving from lying to standing.
• A positive Homans' sign in an immobile client indicates a deep vein thrombosis (DVT), of which Homans' sign (calf pain on dorsiflexion) may be an indicator.
• Encourage frequent toileting is the most effective way to prevent urinary stasis in an immobile client, as regular bladder emptying reduces the risk of urinary stasis and infection.
• Renal calculi is the most likely complication for a client who develops hypercalcemia with prolonged immobility because immobility causes bone resorption, increasing kidney stones.

Nursing Interventions

• Incentive spirometry reduces the risk of atelectasis for an immobile client, promoting lung expansion and prevents alveolar collapse.

• Using a footboard prevents foot drop in an immobile client, as a footboard maintains dorsiflexion.

• The 30-degree lateral tilt position is most effective for preventing pressure ulcers, reducing pressure on bony prominences.

• A high-fiber diet and fluids is the dietary recommendation that should be provided to an immobile client with constipation, promoting bowel motility.

• The primary purpose of applying compression stockings to a client is to prevent DVT (deep vein thrombosis) by improving venous return.

• If a client using a walker complains of wrist pain, and the most likely cause is that the walker is too tall, which forces the client to elevate their shoulders, causing wrist strain.

• "Move both crutches and the affected leg together.” is the correct instruction for using crutches in a three-point gait, which is used when one leg is non-weight-bearing.

• A walker provides the most stability for a client with bilateral leg weakness, providing a wide base of support.

• The cane handle should align at the wrist crease when adjusting a client's cane, when the arm is relaxed.

• "Every 2 hours.” is the best response to a caregiver asking how often to reposition their immobile family member, as repositioning every 2 hours prevents pressure ulcers.

• Move the client's joints through their full range is the correct action about passive ROM exercises, requiring caregiver participation.

• “Use a gait belt around the client's waist.” is the proper instruction to a caregiver transferring a client from bed to chair, ensuring safe handling.

• Encourage weight-bearing exercises is the most effective intervention for an elderly immobile client at risk for osteoporosis.

• Encourage age-appropriate activities intervention is important for a pediatric client with immobility, promoting motor and cognitive development.

• For a pregnant client on bed rest at risk for DVT, apply compression stockings, improving venous return and reduce DVT risk.

• The nurse documents, "client tolerated ambulation with walker for 10 feet without dizziness." this is evaluation, involving assessing the client's response to interventions

• “I'll lift the walker and move it forward." statement by a client using correctly indicates effective teaching, as walkers should be lifted, not slid, to maintain mobility.

• Sudden dyspnea and chest pain for a client with immobility indicates a pulmonary embolism (PE).

• For an immobile client presenting with pitting edema in their lower extremities, elevate the legs to promote venous return and reduces edema An immobile client reports feeling depressed, encouraging socialization and activities can reduce feeling of isolation and depression.

• Encouraging television and reading addresses the clients risk for sensory deprivation, since it prevents sensory deprivation

• Apical pulse should be count for 60 seconds to detect irregularities

• Tympanic is the safest and non-invasive place to take an infants temperature

• Blood pressure of 150/95 mmHg is indicative of someone in the early stages of hypertension Oxygen should be administered to someone who is experiencing symptoms of hypoxemia; SpO2 <90%

• The nurse needs to document and record a heart rate of 120 bpm in a 3 month old, is it falls into the normal range of 100-160 bpm

• Dizziness should be a symptom the nurse expects in an elderly patient who has blood presure of 85/50

• A way to instruct and educate clients is that reduced sodium intake is a major component of maintaining hypertension

• The instructon to “Rest for 5 minutes before checking." is a very correct educational point to teach patients about home blood pressure cuffs

• The nurse should asses for an overdose if the client experiences rapid heavy breathing; Bradypnea (RR <12)

• The nurse needs to provide a client with a light fever/temperature that taking acetaminophen is a good form of treatment

• The cuffs bladder needs to cover 30% of the patients upper arm.

• During respiration tests, Nurses should observe chest movements while prententing to check the pulse.

• To check and asses a patients heart rate, a nurse should note that 90-150 bpm is normal and there are no underlying conditions.

• Older adults should immediately be asssed for signs of infection and contact a doctor, if they have a abnormally low body temperature: 36.0°C

• Nurses need to remember the normal breathing rate for newborns: 30-60 times per minute

• The most effective action the nurse can take is assessing the client for any prior warning sign forstroke

• A patients breathing SpO2 is extremely low and down to 89%, reposition the client

• If the blood pressure gets low for a patient, it is best to contact/administer atropine

• “Less than 140/90 mmHg.”.A normal blood pressure should be in check with an educated caregiver, and not be too high.

• "Remove nail polish before use.” is correct about a home pulse oximeter as nail polish interfers with good results

• The most urgent is that hypotension and tachcardia suggest dehydration

• Hypoxemia and tachcardia suggest dehydration; to provide adequate hydration

• That one must simulate the patient breath deeply

• When assessing a toddlers blood pressue a good thing the nurse must do is

• Athletes always have a good athletic heart rate

• The correct diagnostic tool the nurse documents has, BP150/92 mmHg and 148/90, meaning patient has a high blood pressure

• A quick step the nurse would look for the radial pulse

• A client that is experiencing symptoms or taking certain medications should not continue at the present heart rate

• The patient with COPD, can be given great support with his/her pursed lip breathing

Crutches

• The number 1 thing you notice is that there is no need you need to help the axilla from extreme damage
• It's great is the person has the strength to lift each stride each time
• If the patient has no leg the nurse does not move

Cane

• If the patient is experiencing pain a cane should be used on the side of the body
• The strongest side provides great better support when the weaking is making movements

Body Mechanics

• You must lift 35 pounds before assistance is needed The strongest base for is to make sure there are no accidents and lock the wheels
• A patient needs to lift the bad to reach chest to prevent any damage to the back

Stretching and Assistance

• Make sure the full range of motion with support is given to keep bones moving
• The patient should use a strap and make sure there is no spinal alignment The patient is having trouble holding a gait you need to pivot

Rapid-Fire Questions

• Timed up and Go (evaluate a fall risk
• Severe balance issues (Walker's most of the support you need
• The key to prevent orthostatic is to to the step down
• All wounds should be kept free from the bed to eliminate tension

Assesment

• The patient should take something to help regulate the breathing function

Assesement and Prioritization

• If the patient is having complications you should not perform
• The patient needs to have adequate vitamin K/Iron levels to have the test to work properly
• Ask for the patients heart rate

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A woman who has a bad allergic response should never have ibprofen Do not leave the door up to any The patient should clean mouth right after use. B The proper action to prevent that from becoming a reality The best response is for the nurse to take blood The patient has a high risk for heart problems There should be great time after the nurse gives a test.

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It all comes down to which side of the body you have to administer the medication the great side can give it

A high risk problem, and high education about how to prevent the test and results

You have to call, let the doctor verify the correct solution.

Verbal test most increase risk 24 Not should you change them

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If the patient has bad heart problems there should be no worries High key,

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