NURS 202 Final Exam prep (Quiz ?'s &
mainly..Modules 1-3, 6/7) questions with
answers
When administering an ophthalmic medication where should the nurse instruct the patient to look?
- ANSWERS🔷🔶💡✔Up at the ceiling
*Rationale
When giving an ophthalmic medication, instruct the patient to look towards the ceiling as the
patient is less likely to blink if looking up and the cornea is protected by the lid. (p.814)
A nurse is preparing to administer an IM injection to a 2-year-old child. The best site to select for the
injection is the....? - ANSWERS🔷🔶💡✔Vastus lateralis muscle
*Rationale
The vastus lateralis muscles is the site preferred for infants and young children because it is the
largest muscle mass and there are no major blood vessels or nerves in this area (p.798).
When administering intramuscular injections, the nurse uses the Z-tract technique when the
medication does what? - ANSWERS🔷🔶💡✔Is irritating to the tissues
*Rationale
The use of the Z tract method is recommended when the medication can be an irritate as the Z tract
method has been shown to be a less painful technique and decreases the leakage of irritating
medications into the subcutaneous tissues (p.800).
The nurse is applying a transdermal pain patch to a patient's upper arm. Which nursing actions are
appropriate? (select all that apply) - ANSWERS🔷🔶💡✔-Wear clean gloves when applying the
patch
-Remove the previous pain patch prior to applying the new one
-Place time, date, and initials on the patch
*Rationale
,When applying a transdermal patch, the patch should be applied to a dry clean area that is free of
hair and matches the manufactures recommendations. Remove the patch from its protective coating
and hold it without touching the adhesive edges and apply by pressing firmly with the palm of hand
for 10 seconds. Place time, date, and initials on the patch. Previous patches should be removed before
applying another and the patches should be removed at the appropriate time. Clean gloves would be
appropriate for the procedure and to keep medication from getting on the nurses' hands. (p.812).
When administering a medication by the buccal route the nurse understands that the medication
should be placed where? - ANSWERS🔷🔶💡✔Against the mucous membranes of the cheek
*Rationale
Buccal means pertaining to the cheek. In this medication administration, the medication is held in
the mouth against the mucous membranes of the cheek until it is dissolved (p. 759).
A patient is diagnosed with liver disease. The nurse realizes that which element of pharmacokinetics
will be affected in this patient? - ANSWERS🔷🔶💡✔Biotransformation
*Rationale
Biotransformation or metabolism is the process by which a medication is converted to a less active
form that takes place in the liver where enzymes await to detoxify the drugs. Biotransformation is
altered in a patient who has an unhealthy liver. Drugs in these patients can accumulate and lead to
toxicity (p.755)
The nurse is planning to administer medications to a new patient. What is the nurse's greatest
priority in administering these medications? - ANSWERS🔷🔶💡✔Before giving the medications,
know what the intended effects are for this patient
*Rationale
When giving a patient medication, it is essential that the nurse understands the intended effects or
the reason the drug is prescribed. Knowing this, the nurse understands what should be expected
versus other signs and symptoms that could be side effects, adverse reactions, or an allergic reaction
(p.755)
The nurse realizes that a medication error has been made and a patient has received the wrong
medication. What should be the nurse's first action when realizing an error has been made? -
ANSWERS🔷🔶💡✔Assess the patient's condition
*Rationale
,When a medication error occurs, the first action the nurse should complete is to assess the patient's
condition as patient safety is a top priority. It then should be reported to the charge nurse, nurse
manager, and provider. (p.769)
The nurse is removing morphine from the automatic dispensing cart and notices that the count by
the machine does not match the count in the drawer. What is the first action the nurse should take? -
ANSWERS🔷🔶💡✔Notify the nurse manager and pharmacy immediately
*Rationale
The nurse has the responsibly to investigate and correct the discrepancy before proceeding any
further. If the totals do not tally and the discrepancy cannot be resolved, then the nurse must notify
the nurse manager and pharmacy immediately (p.752)
Which of the following techniques is correct when administering a subcutaneous injection? -
ANSWERS🔷🔶💡✔Insert the needle at a 45-degree angle to the skin
*Rationale
When giving a subcutaneous injection, the need should be inserted using a 45-degree angle to the
skin while the palm is facing to the side or upward. The needle used in these injections should be
only 3/8ths or 5/8ths inch long, and the skin should spread gently or pinched depending on the
amount of adipose tissue present. No air should be drawn into the syringe before administration.
(p.795)
When administering an intramuscular injection in the ventrogluteal muscle, which is the best
position for the nurse to place the patient for ease in locating the muscle? - ANSWERS🔷🔶💡
✔Side-lying with knee bent and raised slightly to chest
*Rationale
The best position in which to administer an IM injection into the ventrogluteal muscle is the side
lying position as this help locate the site more easily (p.798)
The nurse is preparing to administer an enteric-coated medication to a patient through their
gastrostomy tube. What is the first action the nurse should take? - ANSWERS🔷🔶💡✔Check with
the pharmacy if the medication comes in liquid form
*Rationale
When administering medications through a gastrostomy tube, it is important to first check with
pharmacy to see if the medication comes in a liquid form as this helps ensure the tube does not
, become clogged. Enteric coated medications cannot be crushed making it essential to see if it comes
in another form (p.780).
Which medication right is being violated when the nurse does not return to follow-up with the
patient after pain medication is administered? - ANSWERS🔷🔶💡✔Right evaluation
*Rationale
Right evaluation is apart of the 10 rights of medication administration. After administrating pain
medication, it would be appropriate to follow up to see if the medication was effective. Were any side
effects noted? Adverse reactions? Were the desired effects achieved? (p.773)
When preparing to give medications, the nurse should review the "six rights" of medication
administration to ensure client safety. They include which of the following? - ANSWERS🔷🔶💡
✔Person, route, dose, drug, time, documentation
*Rationale
The six rights of medication administration are the right medication, the right dose, the right time,
the right route, right client, and right documentation. There are other rights included in some
models such as right to education, right to refuse, right assessment, and right evaluation however
room number, action, and expiration date are not apart of the six rights. (p.773)
In order to minimize the risk of contamination the nurse knows that all IV solution bags should be
changed how often? - ANSWERS🔷🔶💡✔24 hours
*Rationale
All IV bags should be changed every 24 hours regardless of how much solution remains to minimize
the risk of contamination (p.1352)
Which of the following steps must the nurse complete in order to change the IV container correctly?
(select all that apply) - ANSWERS🔷🔶💡✔-Verify the label of the new container
-Inspect the IV site for inflammation
-Document all relevant information
*Rationale
To change the IV container correctly, first verify the right container, patient, additives, and dose is
selected. Assess the IV site for presence of inflammation or infiltration because if these are present
the IV needs to be removed. The nurse then can disconnect the tube or remove the cap with clean