Wk4- Clinical Skills Quizzes- Sherpath (2/2)

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Questions and Answers

When preparing to administer a new medication, what would the nurse do first to ensure the patient’s safety?

Perform hand hygiene. (correct)

Compare the written order with the medication administration record (MAR).

Inform the patient about the medication.

Review appropriate nursing considerations.

What is the most important step the nurse can take to ensure that the patient is getting the correct medication?

Assess the patient’s ability to swallow oral medications without difficulty.

Question the patient about his or her experience with this or similar medications.

Compare the medication label with the MAR three times. (correct)

Evaluate the patient’s understanding of the safety issues related to the specific drug.

Which statement or question best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in medication administration?

“Does the patient need her pain medication?”

“Let me know if she complains of any nausea.” (correct)

“What is the quality of her pain now?”

“Tell her she doesn’t have an order for the drug she’s asking for.”

As the nurse is administering medication to a patient, the patient states, “I’ve never seen that pill before.” What is the nurse’s most appropriate response?

Tell the patient that you will review the physician’s order to clarify any discrepancies. Signup and view all the answers

What is the nurse’s best response after noticing that the route of administration has been omitted from a medication order?

Immediately notify the prescriber to request that the order be completed. Signup and view all the answers

When is a patient at a higher risk for a medication administration error?

During a care transition point, such as transfer to another unit Signup and view all the answers

As the nurse is giving a patient his medications, he remarks, “I’ve never seen this blue pill before.” What is the nurse’s correct response?

“Don’t take it. Let me double-check the doctor’s order to make sure this is the correct medication for you.” Signup and view all the answers

What is the best way for the nurse to ensure that the patient does not receive the wrong dose because of a calculation error?

Ask another registered nurse (RN) to verify the calculation. Signup and view all the answers

Which of the following nursing actions will reduce the risk of “wrong route” when administering a medication?

Using an oral dosing syringe when administering oral liquid medication Signup and view all the answers

What is the most appropriate way for the nurse to split an unscored tablet?

Ask the pharmacy if it is appropriate to split the pill and if so, ask them to split and repackage it with the adjusted dose given on the label. Signup and view all the answers

As the nurse is at the bedside preparing to administer a new medication, the patient mentions that he is allergic to the drug. What will the nurse do first?

Withhold the medication. Signup and view all the answers

As the nurse prepares to administer oral acetaminophen, the patient refuses to accept the drug because it doesn’t look like the Tylenol she takes at home. After verifying that the medication and dosage are correct, what is the nurse’s best response?

Explain that drugs often come in different physical forms, depending on the manufacturer. Signup and view all the answers

What is the nurse’s first response when a patient requests another dose of narcotic pain medication before it is time for the next dose?

Work with the patient to find alternative nonpharmacologic means of pain management. Signup and view all the answers

The patient has requested a PRN medication for nausea. Which of the following should the nurse do first?

Check to see when the medication was given last, and make sure the time interval is up. Signup and view all the answers

After requesting a narcotic pain medication, the patient refuses it after the nurse prepares the injection. What is the nurse’s best initial response?

Ask the patient the reason for his refusal. Signup and view all the answers

What is the nurse’s first step in preparing to administer a prescribed medication using an automated medication dispensing system?

Review the medication administration record (MAR). Signup and view all the answers

Which precaution should the nurse observe to ensure patient safety when using an automated medication dispensing system?

Prepare medications for one patient at a time. Signup and view all the answers

Which statement or question best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in using automated medication dispensing systems?

“Let me know if she complains of any nausea.” Signup and view all the answers

Which action by the nurse is most important in protecting the safety of patients and staff when using an automated medication dispensing system?

Refusing to share his or her individual security log-in code for the dispensing system Signup and view all the answers

While preparing a patient's oral medication dispensed from an automated medication dispensing system, the nurse realizes that the pill dispensed is twice the correct dose. What is the nurse’s best action at this time?

Notify the pharmacy to determine if the accurate dose is available. Signup and view all the answers

A nurse is preparing to withdraw medication from an open multi-dose vial. After confirming that the vial contains the appropriate medication and checking the expiration date, what would the nurse do next?

Wipe the rubber seal of the vial with an alcohol swab. Signup and view all the answers

What would the nurse do to remove air trapped in a syringe before withdrawing the syringe from the vial?

Position the tip of the needle in the vial’s airspace, and tap the barrel of the syringe. Signup and view all the answers

How can the nurse prevent negative pressure from building up in the vial when preparing an injection?

Inject a volume of air into the vial equivalent to the volume of medication to be withdrawn. Signup and view all the answers

How can the nurse ensure that medication from a single-dose vial is used appropriately?

Discard the vial and any remaining medication in the vial directly after use. Signup and view all the answers

What will the nurse do after opening a multi-dose vial and withdrawing a dose of medication from it?

Label the vial with the date it was opened and your initials. Signup and view all the answers

When preparing an injection from an ampule, what will the nurse do if liquid is trapped in the neck of the ampule?

Use quick, light finger taps on the top of the ampule to move the liquid. Signup and view all the answers

What is the greatest safety concern when withdrawing medication from an ampule?

Withdrawing glass particles into the syringe Signup and view all the answers

How does the nurse minimize the risk of patient infection when preparing medication from an ampule?

Preserving the sterility of the needle while preparing the medication Signup and view all the answers

Which action minimizes the risk of introducing glass particles into the syringe when drawing medication from an ampule?

Using a filter needle or straw to draw the medication from the ampule Signup and view all the answers

Which action might the nurse take when drawing up medication from an ampule?

Hold the ampule upside down while inserting the filter needle. Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site?

“Let me know immediately if the patient’s dressing becomes damp.” Signup and view all the answers

Which action would the nurse take to minimize the patient’s risk for infection when changing the dressing on a CVAD?

Use sterile technique throughout the process. Signup and view all the answers

How can the nurse minimize the risk of dislodging the catheter when removing a dressing?

Remove the transparent dressing or tape and gauze in the direction of catheter insertion. Signup and view all the answers

What will the nurse do after removing the soiled dressing from a patient’s CVAD device?

Remove the catheter stabilization device, if present. Signup and view all the answers

What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing?

Change the dressing every 48 hours. Signup and view all the answers

After the removal of a PICC, the patient becomes hypotensive, lightheaded, confused, tachycardic, anxious, and short of breath. What should the nurse do next?

Place the patient in the left lateral Trendelenburg position. Signup and view all the answers

While discontinuing a PICC, the nurse meets resistance and the catheter appears stuck. What should be the nurse’s next action?

Stop the procedure and notify the practitioner. Signup and view all the answers

Upon removal of a PICC, the nurse notices that the catheter length is less than the original insertion length. What should the nurse do first?

Notify the practitioner immediately. Signup and view all the answers

Before removing a PICC, the nurse should give what instructions to the patient?

“Take a deep breath and hold it.” Signup and view all the answers

A nurse is providing a patient with instructions about PICC removal. The nurse knows the patient understood the postprocedure instructions when he makes which of the following statements?

“I have to stay in bed for 30 minutes after you take the catheter out.” Signup and view all the answers

The nurse is removing a PICC from a patient being treated for glaucoma. Which instruction should the nurse give this patient?

“Hold your breath but do not bear down.” Signup and view all the answers

A nurse is teaching a student nurse about the type of dressing to place on the insertion site after removing a PICC. Which statement would indicate the student nurse understood the information?

“Place petroleum-based ointment and cover it with an occlusive sterile gauze dressing immediately on the site.” Signup and view all the answers

Study Notes

Medication Administration Safety

Verify patient allergies before administering a new medication.
Always confirm the right medication is given to the patient, especially if they question the appearance of the pill.
If a medication order omits the route of administration, consult a physician before proceeding.

Patient Risk Factors

Patients are at a higher risk for medication administration errors when they have multiple medications, are unfamiliar with their medications, or have a language barrier.
Always reassess before administration if a patient expresses uncertainty about the medication being given.

Responses to Patient Concerns

Respond to a patient questioning a medication’s appearance by reassuring them while confirming the medication is what was ordered.
If a patient refuses a medication, clarify their concerns and double-check that the medication is correct before offering an explanation or alternative.

Using Automated Medication Systems

When preparing to administer medication with an automated system, ensure proper identification of the patient and medication.
To ensure safety, always check the medication dispensed to prevent overdose.
Nursing assistive personnel (NAP) can assist in medication administration but do not administer the medications themselves.

Multi-Dose and Single-Dose Vials

Check the expiration date on multi-dose vials before drawing medication.
To prevent air bubbles in the syringe, draw back slightly on the plunger after inserting the needle into the vial.
After opening a multi-dose vial, label it with the date of opening and ensure it is stored correctly to prevent contamination.

Ampule Preparation

When drawing from an ampule, tap the ampule to move liquid down into the body, ensuring it is clear before breaking.
Use a filter needle or filter straw to avoid glass particles when withdrawing medication from an ampule.
To minimize infection risk, clean the top of the ampule before drawing.

Central Venous Access Devices (CVAD) Care

Use sterile technique when changing dressings on CVAD to reduce infection risk.
Secure the catheter properly to reduce the chance of dislodgment during dressing changes.
After removing a soiled dressing, inspect the site for any signs of infection or complications.

PICC Line Removal Procedures

If resistance is felt when removing a PICC line, stop and assess the situation before proceeding.
Monitor the patient for vital sign changes like hypotension or confusion after PICC removal, which could indicate complications.
Instruct patients to perform specific actions, such as holding their breath, during the removal process to prevent complications.

Patient Education and Understanding

Reinforce post-procedure instructions by asking patients to repeat what they have learned.
Use clear and engaging methods to convey information regarding care for their CVAD site after dressing changes.

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Description

Ensuring the Six Rights of Medication Administration Preventing Medication Errors Handling Medication Variations Using Automated Medication Dispensing Systems Preparing Injections from a Vial Preparing Injections from an Ampule Performing Dressing Care for a Central Venous Access Device (CVAD) Peripherally Inserted Central Catheter: Removal