NUR155 / NUR 155 Exam 4 V2 | Latest 2026/2027 Update | Foundations of Nursing | Galen | Correct Questions & Accurate Solutions

NUR155 / NUR 155 Exam 4 V2 | Latest 2026/2027 Update | Foundations of Nursing | Galen | Correct Questions & Accurate Solutions _____ is the application of the internet and other related technologies in the health care industry to improve the access, efficiency, effectiveness, and quality of clinical and business processes utilized by health care organizations, practitioners, clients, and consumers in an effort to improve the health status of clients. E-health A high level of ____ resulting in agitation and the inability to focus or concentrate can also inhibit learning. anxiety Repetition of key _____ and facts facilitates retention of newly learned material. concepts A client's learning style may be based in that client's _____ background. cultural The person who is not ready to learn is more likely to _____ the subject or situation. avoid _______ depicts learning as a complex cognitive activity. Cognitivism The ____ domain, the "skill" domain, includes motor skills such as giving an injection. Psychomotor A nurse would adhere to all of the following guidelines for teaching clients from various ethnic backgrounds EXCEPT: a. obtains teaching materials, pamphlets, and instructions in languages used by clients. b. Uses visual aids, such as pictures, charts, or diagrams, to communicate meaning. c. Invites and encourages questions during teaching. d. Uses medical terminology or health care language, such as "taking your vital signs" or "apical pulse". d. When a nurse is using demonstration as a teaching strategy, which major type of learning would it be? a. psychomotor b. cognitive c. Affective d. All types of learning a Which of the following is the process by which a person learns by observing the behavior of others? 1. Modeling 2. Imitation 3. Trial and error 4. Positive reinforcement 1 Teaching a client how to self administer insulin is in the ____ domain. 1. Sensorimotor 2. Psychomotor 3. Cognitive 4. Affective 2. In which of the following situations would the nurse be applying the humanistic theory? 1. Encouraging the learner to establish goals and promote self-directed learning. 2. Encouraging a positive teacher-learner relationship. 3. Providing a social, emotional, and physical environment conducive to learning. 4. Selecting multisensory teaching strategies since perception is influenced by the senses. 1. In teaching a client about heart disease, the client may need to know the effects of smoking before recognizing the need to stop smoking. In this situation, what factor can facilitate client learning? 1. Readiness 2. Active involvement 3. Motivation 4. Allotted time 3 Many factors inhibit learning. Which of the following is a barrier to learning? 1. The client receives adequate support from family members. 2. The client exhibits emotional readiness to learn. 3. The client is experiencing an acute illness. 4. The client is physically ready to learn. 3 Which of the clients behaviors may cause a nurse to suspect a literacy problem? 1. The client displays a pattern of compliance. 2. The client reads the instructions slowly. 3. The client recognizes that he or she does not know the information. 4. The client states a pattern of excuses for not reading the instructions. 4 Which of the following is a learning outcome for a teaching plan? 1. The client knows the factors that affect blood sugar level. 2. The client selects low-fat foods from a menu. 3. Teach the client about cardiac risk factor. 4. The client understands a low-salt diet. 2 E-health includes all of the following EXCept: 1. a client making an online appointment 2. e-mail access between the client and health care provider. 3. online health information 4. a billing statement sent to the client's home address. 4 Which of the following is NOT an element in the nursing history that provides clues to learning needs? 1. Age 2. Economic factors 3. Client's support systems 4. Sexual preference 4 Which of the following means having too much muscle tone? a. meningitis b. paresis c. flaccid d. spastic d Which of the following is NOT one of the three factors that collectively predispose a client to the formation of a thrombophlebitis (a clot that is loosely attached to an inflamed vein wall)? a. increased oil in the diet b. Impaired venous return to the heart c. Hypercoagulability of the blood d. Injury to a vessel wall. a A nurse is planning a seminar on preventing back injuries. Which of the following statements is correct? 1. When sitting for a long period of time, periodically move legs and hips, and flex on hip and knee, and rest your foot on an object if possible. 2. When sitting, keep your knees slightly lower than your hips. 3. Use hard mattress and firm pillow that provide good body support at natural body curvatures. 4. Exercise regularly to maintain overall physical condition and regulate weight; include exercises that strengthen the pelvic, abdominal, and spinal muscles. 4 During discharge planning, the nurse is teaching the client how to control postural hypotension. Which of the following statements if correct? 1. Bend down all the way to the floor and stand up quickly after stooping. 2. Wear elastic stockings day and night to inhibit venous pooling in the legs. 3. Use a rocking chair to improve circulation in the lower extremities. 4. Get out of a hot bath very quickly, because high temperatures can lead to venous pooling. 3 Crisis _____ is a short-term helping process of assisting clients to work through a crisis to its resolution and restore their precrisis level of functioning. intervention` ______ focuses on solving immediate problems and involves individuals, groups, families. a. Crisis intervention b. caregiver burden c. Crisis counseling d. burnout c _______ diverts urine from the kidney into a stoma. Nephrostomy A _______ may be formed when the bladder is left intact but voiding through the urethra is not possible. (e.g. due to an obstruction or a neurogenic bladder) vesicostomy ______ refers to a lack of urine production anuria ________ ________ a test that uses 24 hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function. Creatinine clearance _____ low urine output oliguria Normal bladder capacity is between ______ mL of urine. a. 300 and 600 b. 600 and 900 c. 900 and 1,200 d. 1,200 and 1,500 a. An infant may urinate as often as ____ times a day. a. 5 b. 10 c. 15 d. 20 d. About ____ % of all 6-year olds experience difficulty controlling the bladder. a. 10 b. 20 c. 30 d. 40 a Although people's patterns of urination are highly individual, most people void about ____ times a day. a. 3 to 4 b. 5 to 6 c. 7 to 8 d. 9 to 10 b All of the following refers to the process of emptying the bladder EXCEPT: a. micturition b. voiding c. urination d. elimination d. Urinary frequency is: 1. voiding two or more times a night. 2. voiding at frequent intervals, that is, more than four to six times per day. 3. the sudden strong desire to void. 4. voiding that is either painful or difficult. 2. During discharge planning, the nurse is teaching the client ways to prevent a recurrence of a UTI. Which of the following actions is correct? 1. Drink six 6-ounce glasses of water per day to flush bacteria out of the urinary system. 2. Wear nylon rather than cotton underclothes. 3. Girls and women should always wipe the perineal area from back to front following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra. 4. Avoid tight fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area. 4. A nurse is evaluating a clients understanding of intermittent self-catherization. Which of the following statements indicates a need for further teaching? Intermittent self-catherization: 1. reduces incidence of urinary tract infection. 2. enables the client to retain independence and gain control of the bladder. 3. allows normal sexual relations without incontinence. 4. protects the lower urinary tract from reflux. 4 Which of the following is an abnormal color or clarity of urine? 1. straw 2. amber 3. dark amber 4. transparent 3 A nurse is testing urine for specific gravity. Which of the following would be considered normal result range? 1. 0.100 - 0.999 2. 1.000 - 1.050 3. 1.010 - 1.025 4. 1.050 - 1.100 3 Elimination of ____ products of digestion from the body is essential to health. waste ______ is the most common bowel-management problem in the elder population. Constipation The colon (large intestine) in the adult is generally about 125 to 150 cm (50 to 60 in.) long. True or False True _____ is a condition that can occur when the veins become distended, as can occur with repeated pressure. Hemorrhoids ____ ______ is a mass or collection of hardened feces in the folds of the rectum. Fecal impaction _______ ____ is increased peristalsis of the colon after food has entered the stomach. Gastrocolic reflex The contents of the colon normally represent foods ingested over the previous __ days. a. 2 b. 3 c. 4 d. 5 c All of the following may be causes of factors that contribute to constipation EXCEPT: a. lack of privacy b. daily routines c. insufficient fiber intake d. insufficient fluid intake b All of the following are thought to contribute to constipation EXCEPT: a. overuse of laxatives b. bland diets c. irregular defecation habits d. exercise d Which of the following feces consistency would be considered abnormal? a. soft b. moist c. semisolid d. dry d A gastrostomy is an opening: 1. through the abdominal wall into the stomach. 2. through the abdominal wall into the jejunum. 3. into the colon (large bowel) 4. into the ileum (small bowel) 1 Which type of enema is given primarily to expel flatus? 1. retention 2. carminative 3. return-flow 4. cleansing 2 Which of the following actions is NOT appropriate for the nurse removing a fecal impaction? 1. Place a bedpan under the client's buttocks and a bedpan nearby to receive stool. 2. Ask the client to assume a right side-lying position, with knees flexed and the back toward the nurse. 3. Drape the client for comfort and to avoid unnecessary exposure of the body. 4. Gently insert the index finger into the rectum and move the finger along the length of the rectum. 2 A nurse is evaluating a client's understanding of healthy defecation. Which of the following statements indicates a need for further teaching? 1. "I will include high-fiber foods, such as vegetables, fruits, and whole grains, in my diet." 2. "I will maintain a fluid intake of 4,000 to 5,000 mL each day." 3. "I will allow time to defecate, preferably at the same time each day." 4. "I will avoid over-the-counter medications to treat constipation and diarrhea." 2 (maintain a fluid intake of 2,000 to 3,000 mL per/day) During discharge planning, the nurse is teaching the client how to manage diarrhea. Which of the following action is NOT correct? 1. Drink at least 8 glasses of water per day to prevent dehydration.. 2. Eat foods with sodium and potassium 3. Increase foods containing insoluble fiber, such as high fiber whole wheat and whole grain breads and cereals, and raw fruits and vegetables. 4. Limit fatty foods. 3 The nurse is promoting regular defecation for a client whom she is taking care of. Which of the following actions by the nurse is NOT correct? 1. A client should be encouraged to defecate when the urge is recognized. 2. Regular exercise helps clients develop a regular defecation pattern. 3. Although squatting position best facilitates defecation, on a toilet seat the best position for most people seems to be leaning backward. 4. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet. 3 A primary care provider orders examination of stool for signs of intestinal infection. What color of stool would the nurse expect to see? 1. red 2. green 3. black 4. white 2 A nurse is evaluating a nursing student's understanding of the actions of enema solutions. Which of the following statements demonstrates a need for further teaching? 1. Hypertonic solutions draw water into the colon. 2. Hypotonic solutions distend the colon, stimulate peristalsis, and soften feces. 3. Isotonic solutions lubricate the feces and the colonic mucosa. 4. Soapsuds solutions irritate the mucosa and distend the colon. 3. Rationale Oil solutions lubricate the feces and the colonic mucosa. Isotonic solutions distend the colon, stimulate peristalsis, and soften feces. Hypotonic solutions distend the colon, stimulate peristalsis, and soften feces. Hypertonic solutions draw water into the colon. What are the drug classifications? Prescription and OTC Generic name or Trade/Brand Name Nurse must have what to administer meds? Physician's orders Controlled Substance system tracking in KY? KASPER What is the US legislation for med admin? Keep drugs on or off the market What is the point of state laws for med admin? Restrictions on certain OTC drugs What are drug effects? the physiologic reactions of the body to a drug Drug side effects (secondary effect) Expected and treated; may be harmless or potentially harmful Drug Adverse Reactions (adverse effects) Are not expected; deadly; may justify the discontinuation of the drug Drug Toxicity too much/ overdose; ingestion of a drug intended for external use or buildup of the drug in the blood because of impaired metabolism or excretion; elderly/kids at risk, kidney/liver Drug Allergy Effects Anaphylactic reaction, happens immediately after the drug is administered, does not mean you have a side effect of the drug Drug Interactions occurs when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs; contraindications, drug compatibility drug half life amount of time for half the med to get out of the body Drug Onset The time it takes for the med to start to work Peak Plasma Level Highest level of med Peak Plasma Level PO 30-60 Peak Plasma Level IV when med is done Drug Trough Right before dose / lowest amount Drug Absorption the process by which a drug is passed into the bloodstream; first step in the movement of the drug through the body Drug Distribution the transportation of a drug from it's site of absorption to it's site of action Drug Biotransformation culturally responsive nursing care centered on client's cultural perspectives; integrates client's values and beliefs into plan of care; develops self-awareness of nurse's own culture, attitudes, and beliefs; examines nurse's biases and assumptions about different cultures; nurse gains knowledge and skills to create environment where trust can develop culture thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups; learned and shared patterns subculture people who have distinct identity and are yet related to a larger cultural group; usually shares physical characteristics or ethnic origin with a larger cultural group; examples: occupational (nurses), feminists, etc. multicultural person who has dual pattern of identification and crosses two cultures' (bicultural) lifestyles and sets of values...may happen with a child with parents from two different countries heritage things passed down from previous generations diversity fact/state of being different-- sex, age, culture, ethnicity, socioeconomic status, education level, religion; exists between cultural groups AND WITHIN cultural groups race classification of people according to shared biologic characteristics and physical features ethnicity often used interchangeably with race; relationship of individuals who believe they have distinctive characteristics that make them into a group; may shift over time nationality state/country where one has membership religion system of beliefs, practices, and ethical values about divine/superhuman power worshipped as creator/ruler of the universe ethnocentrism belief in superiority of one's own culture/lifestyle prejudice pre-concerned notion or judgment that is not based on sufficient knowledge; may be favorable or unfavorable racism assumptions held about racial groups which include the belief that races are biologically discrete and exclusive groups that are inherently unequal and ranked hierarchically discrimination differential and negative treatment of individuals on the basis of race, ethnicity, gender, or group membership generalizations statements about common cultural patterns; may not hold true at the individual level and should only serve as openings for individuals to better understand each other stereotyping assumption that an individual reflects all characteristics associated with being part of a certain group health disparities differences in care experienced by one population compared with another population substandard quality of care; inadequate access to care tow major factors contributing to health disparities social, behavioral, environmental, biologic/genetic four determinants of health health equity the highest possible standard of health for all people, especially those at greatest risk for poor health National Partnership for Action to End Health Disparities; National Stakeholder Strategy for Achieving Health Equity; HHS Action Plan to Reduce Racial and Ethnic Health Disparities; USDHHS Office of Minority Health; CDC Office of Minority Health and Health Equity; National Center on Minority Health and Health Disparities (NCMHD); CDC program REACH U.S.; Healthy People 2020 organizations working to reduce health disparities and emphasize culturally appropriate health care 31...63...43 Census Bureau predictions for 2060: Hispanic/Latins will represent -% of the total population; white non-Hispanics will decrease from -% to -% white nurses are predominantly - and workforce demographics do not reflect national demographics lives; health problems arise culturally responsive care looks at the context in which the client - and the situations in which --- transcultural nursing providing care within differences and similarities of beliefs, values, and patterns of cultures apply knowledge of social/cultural factors that affect nursing/health care across multiple contexts; use relevant data sources and best evidence in providing culturally competent care; promote achievement of safe and quality outcomes of care for diverse populations; advocate for social justice including commitment to the health of vulnerable populations and the elimination of health disparities; participate in continuous cultural competency development things the American Association of Colleges of Nursing Competencies says we should know/do when it comes to cultural competency cultural desire the motivation to want to engage in process of becoming culturally aware, culturally knowledgeable, culturally skillful, and seeking cultural encounters cultural awareness self-exam of one's own prejudices and biases toward the cultures, and an in-depth exploration of one's own cultural/ethnic background cultural knowledge obtaining a sound educational foundation concerning the various worldview of different cultures cultural skills the ability to collect culturally relevant data regarding the client's health in a culturally sensitive manner cultural encounters engaging in face-to-face cultural interactions with persons from diverse backgrounds, and learning to modify one's existing beliefs and prevent possible stereotyping use cultural knowledge by acquiring awareness, attitudes, and skills to care for diverse populations; not possible to learn every cultural perspective, but important to become familiar with cultures in communities that nurses serve things important in providing culturally competent care magics-religious, scientific/biomedical, holistic three views of health beliefs magics-religious view view of health beliefs in which health and illness are controlled by supernatural forces; may believe that illness is a result of "being bad" or opposing God's will; getting well is also dependent on God's will; some cultures believe magic can cause illness through spells and may need magical treatment scientific/biomedical view view of health beliefs that believes life is controlled by physical and biomechanical processes manipulated by humans; illness caused by germs, bacteria, or breakdown of the body; belief that pills, treatments, or surgery will cure holistic view view of health beliefs that believes that forces of nature must be maintained in balance and harmony; human life is one aspect of nature that must be in harmony with rest of nature; when natural balance is disturbed, illness results folk medicine beliefs and practices relating to illness prevention and healing that derive from cultural traditions rather than modern medicine; thought to be more humanistic than biomedical health care; consultation and treatment take place in the community; may be less expensive than scientific or biomedical care; frequently includes ritual practice by healer or client; more comfortable, less frightening to client authority figure in family; value placed on children, other adults; gender-role behavior; extent of family's involvement in hospitalized client's care; needs of extended family; naming systems (family and given name) family pattern variables that are shaped by culture verbal and nonverbal two different types of communication styles that may vary across cultures sibling/family member be careful using ---- for interpreting for client because they may not translate medical jargon very well silence, touch, eye movement, facial expressions, body posture nonverbal communication involves the use of? space orientation different cultures have different -- meaning they have different intimate zones, personal zones, and public zones time orientation different cultures have different -- meaning they have different focuses on past, present, and future nutritional patterns different cultures have different -- meaning that some cultures have strict dietary restrictions awareness, skill, knowledge, encounters, desire what does the ASKED pneumonic stand for in developing self-awareness in which the nurse identifies own cultural beliefs and assumptions/biases awareness "A" in the ASKED pneumonic; am I aware of my biases/prejudices as well as racism and other "isms"? skill "S" in the ASKED pneumonic; do I have the skill in conducting a cultural assessment in a sensitive manner? knowledge "K" in the ASKED pneumonic; am I knowledgeable about the world view of diverse cultural/ethnic groups? encounters "E" in the ASKED pneumonic; do I seek face-to-face and other types of interactions with people who are different from me? desire "D" in the ASKED pneumonic; do I really want to become culturally competent? spend time with client and convey genuine desire to learn their values and beliefs; address client by last name (Mr. Jones, Mrs. Jones, until given permission to use another name); introduce self by full name; be authentic and honest about the culture; use language that is culturally sensitive; consider what client thinks about his/her health problem, illness, and treatment; ask about anything you don't understand; show respect for client's values, beliefs, and practices; show respect for client's support people; obtain client's trust how to convey cultural sensitivity heritage consistent identification with traditional cultural heritage heritage inconsistent acculturation into dominant culture Nature of Pain Involves physical, emotional, and cognitive components Results from physical and/or mental stimulus Reduces quality of life Not measurable objectively Subjective and highly individualized component Types of pain acute, chronic, cancer, inferred pathology, idiopathic Nursing Knowledge - attitude of health care providers - assumptions about patients in pain factors influencing pain age, fatigue, genes, neurological functions, social factors, spiritual factors, psychological factors, cultural factors culture assessment ask about faith and belief systems to understand culture and spirituality relationships Assessment -patients expression of pain - characteristics of pain onset, duration, location, intensity, quality, pattern, relief measures, symptoms pain is the ______ vital sign ? fifth pain scales 11 point scale and Wong/Baker scale (kids) (faces) Tissue Select the correct site to prevent damage to the ______ Sepsis Use sterile equipment and aseptic technique to prevent infection and _____ Side effects and therapeutic action Know the medication you will administer and observe for ______________ Allergies Check for drug _______ before administration of injection Tissue layer Select the appropriate length of needle to deposit the medication in the proper ___________ Patients name The name of the drug The dose Label the syringe with __________ Intradermal route Injection of drugs within or between the layers of the skin; usually used for skin (TB) or allergy testing; forms a skin bleb or small bump 5-15 degree angle What is the angle of insertion used when administering an ID injection? 24, 25, or 27 gauge needle Size of needle used for Intradermal injections Tuberculin syringe Used to administer an intradermal injection; graduated measurements to 1mL Subcutaneous route Injection of a small amount of medication into the tissue below the dermal layer into subcutaneous fat Upper outer portion of the arm Anterior surface of the thigh Abdomen Usual sites for subcutaneous injections 27 gauge, 3/8 to 1/2 inch or 25 gauge, 5/8 inch Size of needle needed for subcutaneous injections 3 mL insulin syringe or tuberculin syringe Type of syringe used for subcutaneous injections 45 or 90 degrees (depending on the amount of subcutaneous tissue of the patient) The angle of insertion for subcutaneous injections Intramuscular injection An injection into deep muscle tissue, usually of the buttock, thigh, or upper arm Deltoid, dorsogluteal, ventrogluteal, vastus lateralis, and rectus femoris Most common sites for a intramuscular injection 19-23 gauge, 1-3 inches long Needle size used for intramuscular injections 90 degree What is the angle for IM injection? 3mL A volume of up to _____ can be administered with IM injections in an adult Syringes made of plastic or glass; used to irrigate wounds, aspirate fluids, or inject medications 3mL syringe Most frequently used syringe Chosen for giving volumes of medication of 1 to 3mL Measures tenths of a milliliter (0.1 mL) Used for most IM injections U-100 syringe/U-50 syringe Used with U-100 strength /U-50 strength insulin Calibrated in units Needle is part of the syringe and is not removable Tuberculin syringe 1 mL in size Calibrated to measure as small as 0.01 mL drug doses 13 to 30 Needles available in standard sizes from ___ to ___ Needle The larger the number the smaller the ______ 25, 27, or 29 gauge Which needle gauges are typically used for ID injections? 25 gauge Which size needle is the most appropriate for a subcutaneous injection? 21-23 gauge What size needle is most appropriate for an IM injection? Ampule A small sealed glass container that holds a single dose of medication; may have glass in them from the breaking of the container Filter needle A special type of needle required when drawing up certain types of medications to keep small particles of glass (from a vial or ampule) from entering the syringe and being injected along with the intended solution Discarded Filter needles are ______ and new needle is attached to syringe for injecting medication into the patient All Report ____ needle sticks Place cap on hard flat surface Scoop cap Press cap and needle on hard surface until cap snaps into place Recapping a clean needle Aseptic technique Use ______ in handling the syringe and needle The needle Tip Inner barrel Plunger Syringe surfaces that must remain sterile Patients name Generic/trade name Dosage Route Time Order for medication must always have these five things Analgesic Medication that reduces or eliminates pain Parenteral route Dispensation of medications via a needle into the skin layers Painful and traumatic IM injections in children are ____ and ____. It is preferable to find another way to give medication if possible Z-track method Used for deep IM injections of drugs such as iron dextran or Vistaril; Reduces pain caused by irritating drugs leaking into sub-q tissue; seals the medication in the muscular layer Anaphyactic shock Circulatory failure from an allergic reaction; symptoms urticaria, bronchiolar constriction, edema, or circulatory collapse Urticaria Hives; an eruption of wheals on the skin accompanied by itching Medication Dosage Route Site Injection documentation should include _________ Z-track method Push and retract skin; insert at 90 degree angle; wait 10 seconds before withdrawing needle slowly; used for medications highly irritating to the tissue MAR or eMAR Routine injections are recorded on the _______ only PRN and stat doses The _____ and ____ doses may also be recorded in the nurses notes, along with the reason the medication was given and the result and duration of effect of the injection 30 minutes Wait ______ after an injection to monitor the patient Date ____ all multidose vials when you open them Vastus lateralis Preferred IM injection site for 1 year old? Ampules Vials Mix-O-Vials Unit dose cartridges Parenteral solutions may be available in ________ Ampules Glass containers with narrow neck, body and stem that are opened by breaking the glass; Usually contain a single dose medication; Tap or flick the stem several times with a finger to free the trapped solution Vials Small bottle with rubber stopper attached by a metal band; May contain one or more dosages; may be in powder for requiring reconstitution. Compatibility Before mixing two medications in a syringe, check for ________ Powdered form Drugs that are unstable in liquid form are prepared in a ________ Sterile water or saline Dilutents are usually ____ or _______ Charts ____ are often available to outline which drugs are compatible Color change Precipitation Clouding Some signs that occur when a drugs combines with an incompatible drug Quick drug action Parenteral routes are used when medications cannot be taken by mouth or __________ is desired Aspirate The nurse should not _____ before the insertion of medication because evidence does not support this practice Nerve, blood vessel, or tissue damage Improper selection of injection site may cause _____ Sterile Injections must be prepared and given using _____ technique to prevent infection ID Subcutaneous IM Routes for parenteral medication Dermal layer The ID route deposits medication into the _______ of the skin 1mL 25,27,29 gauge needle 5/8 inch 5-15 degree An ID injection should be done using a ___ syringe with a ______ gauge needle that is ______ inch long. The needle is inserted at a ____ degree angle and the medication is injected slowly to form a bleb underneath the skin Bleb Fluid-filled raised area under the skin 0.05 to 1 mL ______ of solution may be injected subcutaneously SubQ injections _______ Injections are placed beneath the dermis and above the muscle 45-90 degrees Angle of insertion of a subcutaneous injection; depends on patients size and length of needle used 2-3 mL What is the size of the syringe for an IM injection? 1 to 1 1/2 inch needle that is 23-20 gauge Needle size and gauge for IM injection Gauze The neck of the ampule is wrapped with ____ and snapped open away from the nurse filter needle A ________ is used to draw up medication from an ampule; the needle is changed before administering the injection Larger The _____ the number of the needle gauge, the smaller the needle and the finer the cannula Gauge of needle The selection of a ________ depends on the viscosity of the fluid to be injected and the route of adminstration Long acting first then Short When mixing long and short acting insulin, inject air into the ______ first and then the _____ acting Short acting then Long After injecting air withdraw prescribed amount of ____ acting insulin first and then ____ acting last. Shake When reconstituting a medication from a powder, always rub between your hands, never ______ Side effects of the drug Previous site condition Evidence of therapeutic effect When a repeat injection is given, assess for ________ before administration of the next dose Rotation ____ of sites for medication prevents fibrosis of the tissue Ventrogluteal The _______ IM injection site is the safest site to use in the adult Trochanter Ventrogluteal The head of the ____ and the anterior illiac spine are the landmarks used for this IM injection site? irritating A Z-track technique is encouraged when using medication that is ____ to decrease pain and bruising by sealing the drug into the muscle When do you perform the first check of med administration? Upon removal When do you perform the second check of med administration? While preparing When do you perform the third check of med administration? At bedside What are the 5 rights of med administration? Right time, patient, medication, dosage, route If a patient is administered a medication and has an adverse reaction, what do you do? Assess vitals, stop medication, contact PCP When is a patient's pain usually the worst post-op? 3-4 days If a patient is administered a pain medication and gets a headache, what do you do? See if PRN Tylenol is ordered, contact PCP When pulling medications from a vial, the needle tip should be where? Below the fluid level How do you dislodge any bubbles in the syringe? Tap the syringe barrel What type of needle do you use to withdraw medications? Filtered Before withdrawing a medication from a vial... Inject air into vial Adding a diluent to a powdered drug is known as Reconstitution When administering a non-liquid medication via NG tube, you should... See if the tablet can be crushed--Enteric coated CANNOT be crushed If a medication is in liquid form for NG tube, you must.. Further dilute the liquid with sterile water If you have to crush a tablet to administer via NG tube, you must... Dissolve crushed powder in at least 30 mL of warm water How do you check the placement of an NG tube? Aspirate all stomach contents then measure residual volume OR auscultate If you administer a whole or undissolved medication via NG tube, what will happen? Tube will become clogged When pouring liquid or dissolved medication into the syringe barrel, how do you allow the med to flow? By gravity If the NG tube is connected to a suction, what do you do? Disconnect the suction and keep the tube clamped for 20-30 minutes to enhance absorption If you think a doctor wrote a wrong order, what do you do? Call PCP and verify Before administering a medication you must Verify ID Gauge size for intradermal injection? #25-27 Needle size for intradermal injection? 1/4 - 5/8 inch Maximum amount of volume in intradermal injection? 0.1 mL Sites for intradermal injection? Inner arm, upper back chest, scapula Angle for intradermal injection? 5-15 degrees Regular gauge size for SubQ injection? #25 Insulin gauge size for SubQ injection? #30 Needle size of SubQ injection for an adult of normal weight? 5/8 inch @ 45 degrees Needle size of SubQ injection for an obese adult? 3/8 inch @ 90 degrees Maximum fluid amount of SubQ injection? 0.5 - 1 mL Sites for SubQ injection? Outer upper arm, thigh, abdomen IM injection deltoid syringe size? 1 mL IM injection ventrogluteal syringe size? 3 to 5 mL Maximum fluid amount of IM injection in deltoid 0.5 - 1 mL Maximum fluid amount of IM injection in ventrogluteal 3 mL Why do you aspirate before giving an injection? Make sure you're not in a vessel If you aspirate and get blood... Remove the needle and restart with new needle When inserting a rectal suppository, what end goes first? Lubricated rounded end Position for rectal suppository? Left lateral or left Sims' How should you encourage the client to breathe for a rectal suppository? Through the mouth When finished inserting a rectal suppository... Press buttocks together for a few minutes, ask client to remain in position for 5 minutes What end goes first when inserting a vaginal suppository? Lubricated rounded end How far do you insert a vaginal suppository? About 8-10 centimeters along posterior wall Position for vaginal suppository? Supine Where are topical medications applied? Locally to skin in hairless areas; Side, back, butt Before applying a topical medication, you must... Have an order from PCP When administering a pain patch, you must... Have a nurse witness administration; Sign/date the patch; Put patch in new spot each change When administering a nicotine patch, you must... Put in new spot each change Position for eye medications? Supine If using an eye ointment you must.. Discard first bead because it is considered contaminated Before administering an eye drop you must expose The lower conjunctival sac by pulling down on cheekbone How do you approach the eye when administering an eye drop? From the side Where do you place drops in eye? Onto outer third of lower conjunctival sac Position for ear medications? Side lying When administering an ear med in an adult you must pull the pinna up and back Once the ear drops have been administered you must Press firmly on tragus Bloom's Cognitive domain deals with Thinking, knowing, comprehending Bloom's Affective domain deals with Feelings, attitudes, beliefs, behaviors Bloom's Psychomotor domain deals with Skills, fine/gross motor Before teaching a patient you must Determine how they learn best Type of pain that arises in other parts of the body Referred Type of pain arising from organs Viscera Pain that only lasts through the expected recovery period Acute Pain that is prolonged and interferes with function Chronic Sympathetic nervous system responses to acute pain Increased vitals, diaphoresis, dilated pupils Parasympathetic nervous system responses to chronic pain Normal vitals, dry/warm skin, pupils normal or dilated African Americans believe that pain is A part of life and is to be endured African Americans believe that doing what will free a person from pain? Laying of hands Mexican Americans view pain as A part of life and a sign of strength Puerto Ricans react to pain by Being loud and outspoken When in pain, Chinese value Silence When in pain, Japanese may Refuse pain medication Filipino clients believe that pain is "God's will" How do Buddhist clients respond to pain Remaining calm How do Native Americans respond to pain? Remain quiet, tolerating a high level of pain When in pain Arab Americans will Anticipate immediate relief from pain Nonpharmacologic interventions to control body pain Massage, heat/ice, positioning, acupressure, diet/nutrition, exercise Nonpharmacologic interventions to control mind pain Relaxation, imagery, pain diary, reducing fear, music Nonpharmacologic interventions to control spirit pain Prayer, meditation, meaningful rituals, spiritual healing Nonpharmacological interventions to relieve social pain Pet/family therapy, volunteering, support groups Examples of Opioids Morphine, Hydromorphone, Oxycodone Side effects of Opioids N/V, constipation, sleepiness What type of effect do NSAIDS have Anti-inflammatory Examples of NSAIDS Aspirin, acetaminophen How do NSAIDS relieve pain? By inhibiting COX enzyme Examples of Nonverbal communication Touching, facial expression, eye movement, body posture What is the #1 barrier in communication? Language If there is a language barrier you must Get an interpreter Stage of believe where the client refuses to believe loss is happening Denial If a patient is in denial, the nurse should Verbally support the client Stage of belief where the client or family may direct anger towards nurse or staff Anger If a client is experiencing anger, how should the nurse react Avoid withdraw or retaliation When a patient seeks to bargain to avoid loss they are experiencing Bargaining If a patient is experiencing bargaining the nurse should listen attentively Grieving over what has happened and what cannot be; Client may withdraw or talk freely Depression If a client is experiencing depression, the nurse should Convey caring by touch, communicate nonverbally Coming to term with the loss Acceptance Total response to the emotional experience related to loss Grief Subjective response experienced by surviving loved ones Bereavement Behavioral process through which grief is usually resolved Mourning Experienced in advance of the event Anticipatory grief When a person is unable to acknowledge the loss (abortion, suicide) Disenfranchised grief This loss can be recognized by others Actual This loss can be experienced by one person but cannot be verified by others Perceived This loss occurs when losing a job, death of a child, etc. happens Situational Type of loss that deals with expected moments (departure of child, death of aging parents) Developmental Sources of loss Loss of oneself, object external to oneself, environment, loss of a loved one When a client is dying and experiences loss of muscle tone, what happens? Jaw may sag, difficulty speaking, dysphagia, diminished body movement When a client is dying and experiences slowing of the circulation, what happens Diminished sensation, mottling, cyanosis, decreased BP, slow pulse When a client is dying and experiences changes in respiration, what happens Respirations become rapid, shallow, or abnormal, death rattle occurs, mouth breathing When a client is dying and experiences sensory impairment, what happens Blurred vision, impaired taste and smell What type of care do you provide to the dying patient? Palliative When providing postmortem care, what must be removed from bed? Equipment, soiled linens, all supplies Per agency policy, tubes must be ... Left in place What position do you place a postmortem patient in? Supine After family views the postmortem body, what do you do? Apply ID tags, wrap body in shroud, apply ID to outside of bag Who can perform postmortem care? UAP, nurse The nurse prepares to administer an intramuscular injection to a 4-month old infant. The nurse selects which best site to administer the injection? *Ventrogluteal *Lateral deltoid *Rectus femoris *Vastus lateralis Vastus lateralis The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. *Wash hands *Put gloves on *Place the drop in the conjunctival sac *Pull the lower lid down against the cheekbone *Instruct the client to squeeze the eyes shut after instilling the eye drop *Instruct the client to tilt the head forward, open the eyes, and look down Wash hands, put gloves on, place the drop in the conjunctival sac, pull the lower lid down against the cheekbone A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? *Administer the eye drop first, followed by the eye ointment *Administer the eye ointment first, followed by the eye drop *Administer the eye drop, wait 15 minutes, and administer the eye ointment *Administer the eye ointment, wait 15 minutes, and administer the eye drop Administer the eye drop first, followed by the eye ointment The nurse educator is orienting a new nurse to the pediatric unit and is including tips for medication administration. Which statement by the new nurse indicates that the teaching has been effective? *It helps to use magical thinking with the infant-age group *It helps to use magical thinking with the school-age group *It helps to use magical thinking with the toddler-age group *It helps to use magical thinking with the preschool-age group It helps to use magical thinking with the preschool-age group The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? *I should cuddle my child after giving the medication *I can give my child a frozen juice bar after he swallows the medication *I should mix the medication in the baby food and give it when I feed my child *If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw I should mix the medication in the baby food and give it when I feed my child The nurse is preparing to administer a tuberculin skin test to a client via the intradermal route. Which action should the nurse perform when administering this test to the client? *Inject the medication and place a pressure dressing over the medication site *Make a circular mark around the injection site after administration of the tubreculin test *Administer the injection with the needle bevel facing downward at a 10 to 15 degree angle *Massage the area with an alcohol swab after injection to ensure that the medication is absorbed Make a circular mark around the injection site after administration of the tuberculin test The nurse is preparing to administer an oral medication to an infant. In which position should the nurse place the infant? *Prone *Semi-Fowlers *Trendelenburg's *Dorsal recumbent Semi-Fowler's The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy tube. Which medication prescription should the nurse question? *Furosemide 20 mg via PEG tube daily *Digoxin 0.25 mg via PEG tube daily *Isosorbide mononitrate 30 mg via PEG tube daily *Acetaminophen elixir 650 mg via PEG every 4 hours as needed for temperature 101 F Isosorbide mononitrate 30 mg via PEG tube daily The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply *The right dose *The right route *The right time *The right client *The right staff member *The right documentation The right dose, the right route, the right time, the right client, right documentation A client is in the bathroom when the nurse arrives at his room with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? *Tell the client that he or she will be back when he is finished *Leave the medication at the bedside as the client requested *Let another nurse who is not busy give the client his medication when he is finished *Tell the assistive personnel to give it to the client when he is finished Tell the client that he or she will be back when he is finished The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication? Medications given this way are absorbed more quickly than by other routes The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication? Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry A client has a prescription to receive purified protein derivative, 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines? 26-gauge, 5/8 inch needle inserted almost parallel to the skin, with the bevel side up The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necesssary to contact the PCP if the client is also taking which medications? Select all that apply Warfarin, Glimepiride, Amlodipine The clinic nurse is caring for a client who has been prescribed fentanyl, a potent opioid, for chronic pain. In what forms is it available for chronic pain administration in the at-home setting. Select all that apply intranasal spray, oral transmucosal lozenge, 72-hour transdermal patch, effervescet buccal oralets The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the primary health care provider at standard doses and frequencies would the nurse question? Meperidine hydrochloride by IM route A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy? Dislodgment of the epidural catheter because the catheter is not sutured in place The nurse is preparing to administer medication using a client's nasogastric tube. Which actions should the nurse take before administering the medication? Select all that apply. check the residual volume, aspirate the stomach contents, turn off the suction to the nasogastric tube, test the stomach contents for a pH indicating acidity The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply wash hands, put gloves on, place the drop in the conjunctival sac, pull the lower lid down against the cheekbone The nurse preparing a client for ear irrigation as prescribed by the pcp. Which action should the nurse take when performing the procedure? Warm the irrigating solution to 98.6 The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action? Occlude the nasolacrimal duct with a finger after instilling the drops A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? Administer the eye drop first, followed by the eye ointment The nurse is reviewing the instillation technique for both eye ointment and eye drops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which statement made by the parents would indicate that learning has taken place? I will be careful not to touch the eye or eyelid during administration The nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that to give the ear drops correctly, the mother needs to take which action? Pull down and back on the earlobe and direct the solution toward the wall of the canal Ear drops are prescribed for an infant with otitis media. Which is the most appropriate method to administer ear drops to an infant? Pull down and back on the pinna, and direct the solution toward the wall of the canal A client being discharged to home with a prescription for eye drops to be given in the left eye has received instructions regarding self-administration of the drops. The nurse determines that the client needs further instruction if, on return demonstration, the client takes which action? Lies supine, pulls up on the upper lid, and puts the drop in the upper lid The nurse teaching a mother how to administer ear drops to an infant tells the mother to pull the child's ear in which direction? down and back and direct the solution toward the wall of the canal The nurse is caring for a pediatric client who is going to receive a vaccination. Place the nursing actions for performing this procedure in order of priority verify prescription, assess for allergies, obtain parental consent, check lot number and expiration, select appropriate site and administer vaccine, provide vaccination record When communicating with a client who speaks a different language, which best practice should the nurse implement? Arrange for an interpreter to translate The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preference as being characteristic of a Jehovah's Witness if which client statement is made? I cannot have any food containing or prepared with blood Which is the best nursing interventions regarding complementary and alternative medicine? Educating the client about therapies that he or she is using or is interested in using An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? Encourage the client to discuss the use of an herbal substance with the PCP. The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine, developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? Magnetic therapy and massage therapy are a focus of CAM The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority? Identify the food preferences and methods of food preparation for each client The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply. timing, volume, voice tone, ability to share thoughts and feelings The nurse is caring for a non–English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply. increasing client safety, using spiritual practices, reducing health disparities, increasing client satisfaction, preventing misunderstandings between the nurse and the client A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment? Do you have any family problems? The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client? The nurse secures the assistance of a professional interpreter to communicate with the client The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply. The population served will determine the culturally sensitive resources to use for teaching, assessment of a client's preferred learning approach is essential to facilitate the learning process, it is important to have an accurate translator when the nurse and client do not speak the same language The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action? Request permission to move the client to a private room and allow the family members to visit The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called? Cultural imposition The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch? Position hands 2-4 in from the body An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? Support the client's decision not to receive a blood transfusion The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. touch, eye contact, personal space, time orientation Which most essential element should the nurse consider to promote client adherence to care recommendations? Adhering to the client's cultural preferences What elements are essential for the nurse to address to be able to deliver culturally competent care? Select all that apply. Assessing the client's health preferences, Having knowledge of various racial and ethnic groups, Acknowledging personal misconceptions of various ethnic groups, Recognizing that subcultures exist and not every characteristic of the cultural group is present The charge nurse is educating a new nurse on culturally competent communication techniques. Which response(s) made by the new nurse indicates a need for follow-up? Select all that apply I should use a language interpreter for all culturally diverse groups, I should recognize my own biases and address known stereotypes with the client Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? monitoring blood pressure Which medication, if prescribed for the client with glaucoma, should the nurse question? Atropine sulfate A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? The medication causes the pupil to constrict and will lower the pressure in the eye In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action? Consult the surgeon, as there is not sufficient time for the dilative effects to occur. A client with glaucoma is given a prescription for a pilocarpine ocular system. The nurse plans to provide which instruction to the client on how to use the medication? Check the eye each morning to make sure that they system is in place The nurse is performing an admission assessment on a client who has a history of glaucoma and uses latanoprost eye drops. Which assessment finding would indicate a side/adverse effect of these eye drops? Brown pigmentation of the iris The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the primary health care provider (PHCP) has prescribed atropine sulfate and pilocarpine hydrochloride eye drops. The nurse should contact the PHCP before the home visit for which reason? Clarify the prescription for the atropine sulfate The nursing student is assigned to care for a client with glaucoma for whom pilocarpine hydrochloride eye drops have been prescribed. The nursing instructor asks the student to describe the action of the eye medication. Which statement by the student indicates an understanding of the purpose of this medication? The medication increases the blood flow to the retina and also will lower the pressure in the eye Pilocarpine hydrochloride is prescribed for a client with glaucoma. The nurse checks the medication supply room to ensure that atropine sulfate is available for administration in the event that systemic toxicity occurs from the use of pilocarpine hydrochloride. The nurse also monitors for which sign of systemic toxicity? bradycardia Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action? monitoring body weight A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate eye drops as prescribed. The client asks the nurse why this medication is needed, and the nurse provides education. Which statement by the client indicates that teaching has been effective? The medication dilates the pupil of the operative eye The nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride? Atropine sulfate A client has been prescribed betaxolol eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of what item(s)? Blood pressure A client with glaucoma is receiving acetazolamide. The nurse educator provides education to a group of nurses about the indications for and effect of this medication. Which statement by one of the nurses indicates that the teaching has been effective? This works to decrease introccular pressure In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the primary health care provider's prescriptions, expecting which type of eye drops to be prescribed? A mydriatic medication The preoperative medication sheet identifies that cyclopentolate is prescribed for a client before cataract surgery. The client asks the nurse what the medication is for, and the nurse provides education. Which statement by the client indicates that teaching has been effective? It paralyzes the muscles in my eye The nurse would question the primary health care provider if which medication were prescribed for a c