Exam 1 V2: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical Surgical Nursing | Questions & Answers | 100% Correct | Galen

Exam 1 V2: NUR170 / NUR 170 (Latest 2026/2027 Update) Concepts of Medical Surgical Nursing | Questions & Answers | 100% Correct | Galen A nurse is preparing a sterile field. The nurse should identify which of the following actions contaminated the sterile field. Select all that apply. A. A cotton ball dampened w sterile normal saline is placed on the field. B. A contaminated instrument touches the outer edge of the sterile field. C. A sterile instrument is dropped onto the near side of the sterile field. D. The nurse turns to address the client's question concerning the procedure. E. The procedure is postponed for 30 minutes to accommodate the client. F. A liquid is poured into a sterile container from a distance of 25 cm. A. A cotton ball dampened w sterile normal saline is placed on the field. D. The nurse turns to address the client's question concerning the procedure. E. The procedure is postponed for 30 minutes to accommodate the client. F. A liquid is poured into a sterile container from a distance of 25 cm. A nurse should identify that which of the following is the goal of surgical asepsis? A. To create and maintain a micro-organism-free environment. B. To kill all micro-organisms on all instruments involved in a procedure. C.To reduce the presence of pathogenic organisms in the environment. D. To minimize exposure to the clients blood during an invasive procedure. A. To create and maintain a micro-organism-free environment. A nurse is providing teaching to an assistive personal (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give? A. "Ask another team member to assist with donning gloves." B. "Choose a pair of gloves at least one size smaller than usual." C. "Grasp only the underside of the cuff with your ungloved hand." D. "Grasp only the inside of the glove with your ungloved hand." D. "Grasp only the inside of the glove with your ungloved hand." While waiting for a sterile procedure to begin, how do you position your hands and arms? A. With hands clasped together in front of the body above the waist. B. At the sides of the body, with hands pointing downward. C. Folded across the chest with hand on the shoulders. D. With hands clasped together at the back of the body at waist level. A. With hands clasped together in front of the body above the waist. Prior to entering the surgical-scrub area, which of the following personal protective equipment (PPE) items should a nurse don? (select all that apply) A. Gown B. Protective eyewear C. Hair cover D. Mask E. Shoe covers B. Protective eyewear C. Hair cover D. Mask E. Shoe covers A nurse should identify that which of the following areas of the hands requires special attention during the prescribe wash? A. The area between each finger B. The area under each fingernail C. The palm of each hand E. The back of the hands B. The area under each fingernail A nurse is preparing to wash their hands prior to surgery. For which of the following reasons should the nurse keep their hands above their elbows? A. To prevent them from coming into contact with a contaminated object. B. To facilitate the application of sufficient friction to the hands. C. To provide good visualization of the hands as they are scrubbed D. To encourage water and soap to flow away from the clean hands. D. To encourage water and soap to flow away from the clean hands. When opening a sterile pack, which of the following actions would compromise the sterility of the instruments and supplies inside the pack? A. Allowing movement of team members around the field. B. Holding the sterile pack below waist or table level C. keeping sterile items away from the edge of the table D. Opening the sterile pack just prior to the procedure. B. Holding the sterile pack below waist or table level A nurse is preparing to flush and change the dressing on a clients central venous catheter. Which of the following should the nurse identify as the primary purpose for performing this intervention using surgical asepsis. A. To promote the catheter's patency B. To assess the skins integrity around the catheter site. C. To provide a clean, dry environment for the catheter D. To control the introduction of micro-organisms as the catheter site. D. To control the introduction of micro-organisms as the catheter site. A nurse is preparing to open a sterile package of instruments. Identify the order in which the nurse should perform the following steps. A. Open the side flaps. B Open the flap closest to their body C. Open the flap furthest from their body. D. Position the tray, so the top flap is farthest away from their body. D. Position the tray so that the top flap is farthest away from their body. C. Open the flap furthest from their body. A. Open the side flaps. B Open the flap closest to their body When donning sterile gloves, which of the following explains the method a nurse should use for gloving the dominant hand? A. Slipping the fingers beneath the cuff maintains the gloves' sterility. B. The inner edge of the cuff will lie against the skin and thus will not be sterile. C. Gloving the dominant hand first allows for better control over the process. D. The hand has been surgically scrubbed and is considered uncontaminated. B. The inner edge of the cuff will lie against the skin and thus will not be sterile. A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of the following components of the model? A. Sender B. Channel C. Feedback D. Receiver C. Feedback A nurse in a providers office is caring for a client who has hypertension during a follow-up appointment and is focussing on the clients ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations? A. "I'm glad you decided to continue your fitness routine." B. "You could achieve better results if you applied yourself more." C. "You are adjusting very well for your age." D. "Reducing your caffeine intake is good, but you really need to stop completely." A. "I'm glad you decided to continue your fitness routine." A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the clients request? A. Cultural factor B. Developmental factor C. Environmental factor D. Physiological Factor A. Cultural factor A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client states, "I do not know how I will have time for dialysis." Which of the following factors is influencing the clients' communication? (select all that apply) A. Psychosocial factors B. Cognitive factors C. Situational factors D. Environmental Factors E. Physiological Factors A. Psychosocial factors C. Situational factors A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but cannot communicate their pain level. Which of the following actions should the nurse take? A. Administer an antagonist to reverse the effects of the anesthesia. B. Use an alternative method for determining the clients' pain level. C. Administer pain medication as prescribed for severe pain. D. Wait until the client is awake, alert, and can vocalize their pain level. B. Use an alternative method for determining the clients' pain level. A nurse receives a phone call from a client who was discharged yesterday. The client ask the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make? A."The nurse manager will need to email the discharge instructions to you." B. "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act. C. "You will need to ask your provider to email the discharge instructions to you." D. "Sending the discharge instructions to you via email would be a violation of the Affordable Care Act." B. "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act. A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.) A. "Interrupt the client occasionally during the conversation." B. "Respect the client during the conversation." C. "Use complex terms when explaining with the client." D. "Allow time for reflection during the conversation with the client." E. "Show empathy during the conversation with the client.' B. "Respect the client during the conversation." D. "Allow time for reflection during the conversation with the client." E. "Show empathy during the conversation with the client.' A nurse is obtaining a health history from a newly admitted client. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication? A. Auditory B. Nonverbal C. Emotional D. Energetic B. Nonverbal A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using? A. Affirmation B. Open-ended question C. Reflection D. Restating D. Restating A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.) A. Move the client to a quiet area or private room. B. Speak at a slower pace. C. Delay the assessment until the client's family member brings the hearing aid. D. Have a sign language interpreter translate the communication with the client E. Stand next to the client when talking. F. Avoid using medical terminology. A. Move the client to a quiet area or private room. B. Speak at a slower pace. F. Avoid using medical terminology. A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? A. Explain the daily schedule to the client in detail. B. Turn the overhead lights on in the client's room when speaking with them. C. Speak in a loud voice to the client. D. Speak to the client clearly and at a slow pace. D. Speak to the client clearly and at a slow pace. A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take? A. Use medical terminology during teaching. B. Sit across from the client at a table in the cafeteria during teaching C. Ensure the client is wearing their glasses during teaching. D. Use the communication technique of probing during teaching. C. Ensure the client is wearing their glasses during teaching. A nurse instructs a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? A. Identification B. Orientation C. Exploitation D. Resolution C. Exploitation A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.) A. Verbal B. Written C. Electronic D. Nonverbal E. Assertive A. Verbal B. Written D. Nonverbal A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? A. Receiver B. Sender C. Channel D. Decoder B. Sender A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask a staff member who speaks the same language as the client to interpret. B. Ask a family member of the client to interpret the information. C. Search the internet for an electronic application to use for translating. D. Request assistance from the facility's interpreter. D. Request assistance from the facility's interpreter. A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating? A. Assertive B. Aggressive C. Passive-aggressive D. Passive C. Passive-aggressive A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? A. Send an email to staff via the facility's email system. B. Schedule a face-to-face unit staff meeting. C. Place a copy of the policy on a bulletin board in the hallway. D. Leave a voicemail on each staff member's phone. B. Schedule a face-to-face unit staff meeting. A nurse is conducting a preoperative assessment of a client. Which of the following statement is an example of the nurse using motivational interviewing? A. "You said that you're sad. What is making you feel sad?" B. "If you want to lose weight, why do you keep eating fast food?" C. "Have you always struggled with depression?" D. "Do you have any health problems?" A. "You said that you're sad. What is making you feel sad?" A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? A. Ensure the room is well lit. B. Have soft music playing in the background. C. Hand out samples of products during the teaching. D. Speak quickly during the teaching. A. Ensure the room is well lit. A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take? A. Leave the client's room to go check on other clients. B. Ask the client why they are ignoring the question. C. Repeat the question in a loud voice. D. Lower the volume on the television. D. Lower the volume on the television. The client asks the nurse for a copy of their medical record.The nurse knows that this right is part of which regulation 30 sec A. The patient self-determination act. B. HIPAA C. The uniform anatomical gift act. D. The Americans with disabilities act. B. HIPAA Which communication strategies should the nurse use when working w/ a client who has difficulty speaking due to weakness. 60 sec A. Encourage the client to speak quickly B. Ask yes and no questions when able C. Have the client use a communication board D. Repeat what the client said to verify the message E.Use a pen and paper to communicate client needs. F. Encourage verbal communication to strengthen the client's voice. B. Ask yes and no questions when able C. Have the client use a communication board D. Repeat what the client said to verify the message E.Use a pen and paper to communicate client needs. A post-op pt. says "Don't touch me. I'll take care of myself" Whichresponse is therapeutic? A. Fine, I won't touch you. B. Let's work together so you can do things for yourself. C. I have to change your dressing so I have to touch you. D. If that's what you want but I need to report this to the surgeon. B. Let's work together so you can do things for yourself. A nurse performing a home assessment on an older client having weakness would be concerned about which unsafe finding? A. Nonskid surfaces on slippers B. Nonskid backing on small rugs C. Electrical cords taped to the floor D. Bath mats on the shower stall floor E. Electrical appliances and cords near the sink F. Full bathroom on the second floor E. Electrical appliances and cords near the sink F. Full bathroom on the second floor The nurse understands that which are judgemental statements? A. I do not think you need to do that. B. Tell me about making that decision. C. I am not sure that is what is best for you. D. When did you first notice you felt that way? E. I would like to be sure I understood what you said. F. It will be fine. We all feel that way sometimes. A. I don't think you need to do that. C. I'm not sure that's what is best for you. F. It will be fine. We all feel that way sometimes. The nurse is teaching a pt. about home safety. Which recommendations would they include? A. Remove wall to wall carpeting. B. Use nightlights during nighttime. C. Place handrails in bathtubs and showers. D. Check staricase railings for secureness and sturdiness. E. Place scatter rugs on hardwood floors and at the bottom of a staricase. F. Use extension cords for additional lamps to provide adequate lighting. B. Use nightlights during nighttime. C. Place handrails in bathtubs and showers. D. Check staricase railings for secureness and sturdiness. When discussing a health care plan with an Amish client, the nurse should perform which actions? A. Speak only to the client. B. Avoid using medical terms. C. Maintain adequate personal space. D. Use complex scientific terminology. E. Stand close to the client and speak softly. F. Establish a helping relationship. B. Avoid using medical terms. C. Maintian adequate personal space. F. Establish a helping relationship. The nurse understands that personal health information can be disclosed in which situations? A. Compliance with legal proceedings. B. For research purposes in limited circumstances. C. To a family member or significant other in an emergency. D. To nonessential medical personnel involved in client care. E. To appropriate military if a client is a member of the armed forces. F. During lunch break with colleagues who work in another unit. A. Compliance with legal proceedings. B. For research purposes in limited circumstances. C. To a family member or significant other in an emergency. E. To appropriate military if a client is a member of the armed forces. The hospice nurse has established a helping relationship with the client and family. Which actions are most appropriate? A. Encouraging family discussions of feelings. B. Accepting the family's expressions of anger. C. Restricting client visits to scheduled hospital visiting hours. D. Facilitating the use of spiritual practices identified by the family. E. Keeping the family informed of changes in the client's condition. F. Making decisions for the family during difficult moments. A. Encouraging family discussions of feelings. B. Accepting the family's expressions of anger. D. Facilitating the use of spiritual practices identified by the family. E. Keeping the family informed of changes in the client's condition. A nurse is teaching a client how to self administer tube feedings at home. The client expresses concern. Best response? A. Does your family know about this concern you have? B. Is there a family member or friend that is willing to help you? C. Do you want me to prescribe home visits from the nurse for you? D. Let's talk about what makes it hard for you to perform this procedure. D. Let's talk about what makes it hard for you to perform this procedure. Which nursing actions can result in disciplinary action by state boards of nursing? A. Release of client health information to a client's neighbor. B. Delegation of a dressing change to UAP. C. Release of client health information to the client's durable POA. D. Admin. of a routine immunization that resulted in an allergic reaction. E. Admin. of an injection to client who refused the medication. F. Diverting medication from the medication dispensing system. A. Release of client health information to a client's neighbor. B. Delegation of a dressing change to UAP. E. Admin. of an injection to client who refused the medication. F. Diverting medication from the medication dispensing system. Which clients may be assigned to a LPN/LVN? A. A client requiring oral medication. B. A client requiring an admission assessment. C. A client requiring an intravenous injection. D. A client requiring a subcutaneous injection. E. A client requiring an intramuscular injection. F. A client requiring insertion of a urinary catheter. A. A client requiring oral medication. D. A client requiring a subcutaneous injection. E. A client requiring an intramuscular injection. F. A client requiring insertion of a urinary catheter. Which tasks would be appropriate for the nurse to delegate to UAP? A. Assist new post-op client to the bathroom. B. Set up the clients' lunch trays. C. Change a central line dressing. D. Teach a client how to administer discharge medications. B. Set up the clients' lunch trays. Which are the best resources to refer to for information r/t scope of practice? A. Hospital policies and procedures. B. Nurse Practice Act. C. Ordering physician. D. Hospital pharmacist. E. Food and Drug Administration. F. The nursing process. A. Hospital policies and procedures. B. Nurse Practice Act. Pt. is admitted w/ dx of a stroke and hx of dementia. Which nursing dx ha: highest priority? A. Bathing/hygiene self care deficit. B. Potential for injury. C. Imparied physical mobility. D. Distrubed thought process. B. Potential for injury. Which of these actions by the nurse is the most effective means of preventing infection? A. Rub hands with cloraz wipes when visibly dirty. B. Perform hand hygiene before reporting for work. C. Wear sterile gloves when giving IV medications. D. Use alcohol based sanitizer when hands are not visibly soiled. D. Use alcohol based sanitizer when hands are not visibly soiled. The nurse finds pt. on the floor. After examining and assisting the pt. back to bed, which action should the nurse take 1st? A. File an incident report. B. Put the bed alarm back on. C. Place the client in 1:1 observation. D. Notify the nurse manager. B. Put the bed alarm back on. Which statements describe current US health care delivery practices? A. Access to care depends on ability to pay, not availability of services. B. The pt protection and ACA provides private health insurance to underserved C. All insurance plans in the Marketplace offers comprehensive coverage. D. 50 vears ago 50% of doctors practiced primary care, todav it's 1 in 3. E. Quality of care = the right care for the right person at the right time. C. All insurance plans in the Marketplace offers comprehensive coverage. D. 50 vears ago 50% of doctors practiced primary care, todav it's 1 in 3. E. Quality of care = the right care for the right person at the right time. Which of these patients are receiving secondary health care? A. A patient enters a community clinic w/ signs of strep throat. B. A patient is admitted to the hospital following a heart attack. C. A mother brings her son to the ED following a seizure. D. A pt w/ osteogenesis imperfecta is being treated in a medical center. E. A father brings his son to a specialist to correct a congenital heart defect F. A woman has a hernia repair in an ambulatory care center. B. A patient is admitted to hospital following a heart attack. C. A mother brings her son to the ED following a seizure. F. A woman has a hernia repair in an ambulatory care center. How would the nurse explain respite care? A. Respite care is a service that allows time away for caregivers B. Respite care is a special service for those who are terminally ill. C. It is direct care provided to people in a TC facility. D. It provides living units for people without regular shelter. A. Respite care is a service that allows time away for caregivers Which patients would the nurse consider high risk for falls? A. A patient older than 50. B. A patient who has already fallen twice. C. A patient who is taking antibiotics. D. A patient who experiences postural hypotension. E. A patient who is experiencing nausea from chemotherapy. F. A 70 V/o who is transferred to LTC. B. A patient who has already fallen twice. D. A patient who experiences postural hypotension. F. A 70 V/o who is transferred to LTC. The nurse orients an older adult to the safety features in her hospital room. What is the priority component of this routine A. Explain how to use the telephone. B. Introduce the patient to their roommate. C. Review the hospital policy on visiting hours. D. Explain how to use the call bell. D. Explain how to use the call bell. Which point indicates that the nurse possesses the ability to write objectives clearly and concisely? A. Inclusion of the timeline and deadline. B. Expectations are open to interpretation of health care providers. C. Uses medical terminology with Latin origins only. D. Specifying multiple dates for the attainment of a goal. A. Inclusion of the timeline and deadline. A nurse explains evidence-based practice to a new grad by stating... A. Nursing care based on tradition. B. Scholarly inquiry of nursing and biomedical research literature. C. It is a problem-solving approach that integrates the best current evidence. D. Quality nursing is provided in an efficient and economically sound manner. C. It's a problem solving approach that integrates best current evidence. Interpersonal communication, or self-talk, is the communication that happens within the individual. TRUE or FALSE FALSE Communication is influenced by the way people value themselves, one another, and the purpose of any human interaction. TRUE or FALSE TRUE In order for a communication process to occur, three components are needed: a source or sender, the message, and the _____________, the medium the sender selects to send the message. channel Incivility is rude, disruptive, intimidating, and undesirable behavior directed at another person. TRUE or FALSE TRUE An example of an open-ended question is: "What medicines have you been taking at home?" TRUE or FALSE FALSE During the _______________ phase of the helping relationship, the tone and guidelines for the relationship are established. orientation Factors that distort the quality of the message, known as ____________ , can interfere with communication at any point in the process. noice The therapeutic communication technique known as ____________ is the skill of identifying with the way another person feels. empathy An intimate communication zone occurs during the interaction between parents and children, whereas a ______________ zone occurs when people interact with close friends. personal Rapport refers to a feeling of mutual trust experienced by people in a satisfactory relationship. TRUE or FALSE TRUE Identify the RN's role and responsibility in medication administration Responsible for administering medications. Must have knowledge of the patient, of the medicine, standards of care (3 checks and 12 rights), Nursing skills (able to assess patient), Accountability (good ethics), and must have critical thinking and nursing judgement skills What are the 12 Rights? Right: Dose, Route, Documentation, Reason, Allergies (reaction), Medication, Education (for the patient), Refuse, Time, Response, Assessment, Patient How many checks are completed before giving medications for patient to ingest? 3 checks, 2 outside of the room and 1 inside the room List and describe the 7 parts to a medication order Patients full name and DOB, Date and Time, Name of medication, Route of administration, Frequency, Duration of therapy as appropriate, Signature/Title of person who ordered the medication When would you not administer a PO medication? If patient is unconscious, NPO, vomiting or having difficulty swallowing What types of medications can NOT be crushed/broken/chewed? Enteric coated or extended release What is the route of a sublingual medication? placed under the tongue What is the route of a buccal medication? placed between upper or lower molar and teeth and cheek (document what side is used) What should be written on a transdermal patch when its on a patient? Date, Time, Initials Where do you apply a transdermal patch? onto clean, dry, hairless, intact skin Would you wear gloves when applying and removing transdermal patches? YES How do you hold the ear of an adult when administering ear drops? Pull auricle up & back How do you hold the ear of an school aged child when administering ear drops? pull auricle straight back How do you hold the ear of a child under the age of 3 when administering ear drops? pull auricle down and back What is does a bronchodilator do? helps airway relax to open bigger immediately (typically 2 puffs) What does a corticosteroid do? Helps to reduce inflammation in the lungs over time, you should use a bronchodilator first and then the corticosteroid. What is an example of a bronchodilator? Albuterol Before giving a Nebulizer treatment, what should the nurse do first? The nurse should asses the patients respiratory system. Check Respiration rate, pulse ox, and listen to the lungs, so that way they check check after treatment to assure that it helped. What does PEG tube stand for and where is it located? percutaneous endoscopic gastrostomy tube, its located outside the patients abdominal wall How would you verify tube placement of a PEG tube? measure length of exposed tube, visualize stomach contents How much sterile water do you flush a PEG tube with? 30mL How much sterile water do you add to a crushed medication if giving through a PEG tube? 15mL How much sterile water do you use between crushed medications when administering medication through a PEG tube? 10mL How elevated should the head of the bed be when administering PEG tube medications? Never lower than 30 degrees What are types of Vaginal medications? creams, foams, tablets, suppositories What should a nurse ask a patient before administering a vaginal suppository? To void (urinate) How far should a nurse administer a vaginal suppository into the vaginal canal? 2-4 inches After administering a Vaginal suppository, how long should a patient remain in the supine position? 5-10 minutes What are types of Rectal medications? suppositories, enemas, creams, lotion, or ointment What position should patients be in when administering rectal medications? Left lateral or left sims How far should a nurse administer a rectal medication? about 4 inches What should the patient do as you insert a rectal medication? breathe through their mouth How long after insertion of a rectal medication should a patient remain on side? 5 minutes When would you not administer a rectal medication? recent rectal or bowel surgery, prostate surgery, or rectal bleeding When would you hold a medication order? You would hold a medication order if the patient is to receive a medication that they are allergic to, if the parameter set for the medication are not met to be administered which is correct? A. Units B. U C. Both are acceptable A. Units When do medications get reconciled ? Admission, Transfer to another setting or level of care, After surgery, and Discharge Are nursing students able to take verbal or telephone orders? No What is the normal range for a serum potassium level? 3.5-5 mEq When administering a blood pressure medication, at what systolic mmHG should you hold the medication? 110 or lower, hold the medication When administering medications, what should you ask the patient before giving? Name, DOB, and any allergies When should you use a oral syringe when administering liquid medication? When the dose is less than 5mL of medication When checking for the Right Patient, what must nurse do? Check the MAR, then the bracelet for name a DOB When checking for reaction (allergies) what must the nurse do? make sure the medications ordered are not allergies for the patient when checking for the right medication, what should the nurse do? compare the labels of the drug to medication list on the MAR 3 separate times When checking for the right dose, what must the nurse do? Look at the medication on the MAR, look at normal dose range When checking for the right route, what should the nurse do? look at the route, make sure that it is acceptable for the patient, if it is not noted NEVER assume When checking for the right time, what must the nurse do? See when the medication is due, verify when it is due. Look at the frequency to make sure that it is acceptable to have within that time. Needs to be given within 30 minutes before or after time needed When checking for the right reason, what should the nurse look for? Read the chart, make sure it's appropriate for the patient to get the med. Ask yourself, Why does the patient need the medication? Be able to answer your question When checking for the right assessment of the patient, what should the nurse assess? The nurse may need to get vital for some of the medications being given. There may be set parameters for some medications What exercising the right to patient education, what should the nurse do? The nurse should inform the patient of all the side effects and why they are to receive that medication What a patient exercises their right to refuse, what should the nurse do? The nurse should educate the patient on why they need the med and maybe they'll change their mind. If they still do not want to medication, document that they refuse the medication and why When the nurse has the right documentation what does that mean? You document that the medication was given AFTER it was administered, you would document lab values, vitals, any information needed for your patients chart. What is the right response in medication administration? you would asses before and after the medication is given to see if there is a change that is what the medication was wanted for. Ex: asses pain prior to and after receiving medication to see if the medication worked