Question

In assessing the skin condition of an elderly client, the nurse notes that, over the sacral area, there is a 2-cm to 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

Answer 1

Correct Answers:

"2-cm to 3-cm reddened area on sacrum with open center. Does not blanch."

Rationale :

🔴 Provides accurate size measurement of the lesion (2–3 cm).

🔴 Describes color and non-blanching to indicate tissue compromise.

🔴 Notes that the center is open, specifying stage II pressure ulcer characteristics.

🔴 Avoids subjective terms such as “massaged” which can be misleading.

🔴 Documentation is clear, concise, and objective, essential for care planning and legal record.

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Answer 2

Correct Answers:

Down and back.

Rationale :

🔴 For children under 3 years, the ear canal is short and straight, requiring downward and backward pull.

🔴 Ensures proper delivery of medication to the middle ear.

🔴 Reduces risk of ear trauma or discomfort during administration.

🔴 Facilitates optimal absorption of the ear drops.

🔴 Follows pediatric medication safety guidelines.

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Answer 3

Correct Answers:

2 mg

Rationale :

🔴 Using numeric “2 mg” avoids confusion or misinterpretation.

🔴 Writing numbers in digits reduces risk of transcription errors.

🔴 “Two mg” or “two milligrams” can be misread.

🔴 Avoids unnecessary trailing zeros, preventing 10× dosing errors.

🔴 Follows safe medication administration standards.

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Answer 4

Correct Answers:

Administer the medication via Z-track.

Rationale :

🔴 Z-track method prevents medication from leaking into subcutaneous tissue.

🔴 Minimizes staining of the skin, which is common with iron injections.

🔴 Increases drug absorption and ensures deep intramuscular delivery.

🔴 Reduces discomfort at the injection site.

🔴 Standard practice for irritating or staining IM medications.

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Answer 5

Correct Answers:

the child's weight

Rationale :

🔴 Pediatric doses are most commonly calculated per kilogram of body weight.

🔴 Weight-based dosing ensures therapeutic effect and safety.

🔴 BMI, height, or developmental stage do not accurately determine drug dose.

🔴 Prevents underdosing or overdosing in children.

🔴 Supports evidence-based pediatric medication administration.

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Answer 6

Correct Answers:

Administering an oral medication with the client sitting upright

Rationale :

🔴 Sitting upright prevents aspiration of oral medications.

🔴 Promotes safe swallowing and absorption.

🔴 Demonstrates adherence to safe medication administration standards.

🔴 Avoids errors such as leaving medications unattended.

🔴 Supports client safety and comfort during administration.

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Answer 7

Correct Answers:

Report the discrepancy to the charge nurse immediately.

Rationale :

🔴 Narcotic discrepancies are high-risk events requiring immediate attention.

🔴 Ensures proper documentation and accountability.

🔴 Protects clients and staff from diversion or errors.

🔴 Immediate reporting allows timely investigation.

🔴 Follows hospital narcotic control policies.

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Answer 8

Correct Answers:

Water soluble

Rationale :

🔴 Water-soluble lubricants do not interfere with absorption of the suppository.

🔴 Prevents chemical interactions or delayed action.

🔴 Easier to clean and remove, promoting hygiene.

🔴 Reduces risk of irritation to rectal mucosa.

🔴 Follows safe and effective rectal medication administration.

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Answer 9

Correct Answers:

False reassurance

Rationale :

🔴 Saying “it will be fine” minimizes client’s anxiety rather than acknowledging it.

🔴 Provides false comfort without addressing concerns.

🔴 Does not offer therapeutic support or coping strategies.

🔴 Can erode trust if complications occur.

🔴 Nurses should validate feelings and provide factual information instead.

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Answer 10

Correct Answers:

"Do you have any allergies to medications?"

Rationale :

🔴 Ensures immediate identification of potential hypersensitivity.

🔴 Prevents adverse drug reactions.

🔴 Critical for safe medication administration planning.

🔴 Protects client safety and legal responsibility.

🔴 Standard part of comprehensive medication history.

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Communication, Pharmacology, Tissue Integrity Exam 2

No.

1 :
In assessing the skin condition of an elderly client, the nurse notes that, over the sacral area, there is a 2-cm to 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

2 :
A 2-year-old child is hospitalized with tonsillitis and bilateral otitis media. The nurse is preparing to administer prescribed ear drops. When instilling the medication, the nurse should pull the child's earlobe?

3 :
The nurse is talking a verb order for a new medication. Which is the most accurate and safest way for the nurse to transcribe an order for a two milligram dose into the client's chart?

4 :
A nurse is preparing to administer iron, a medication that has the potential to stain the skin. Which of the following should the nurse do?

5 :
The pediatric nurse knows the most accurate medication dosage for a child is determined by using which piece of assessment data:

6 :
Which of the following examples best demonstrates safe drug administration by the nurse?

7 :
Which action will the nurse take when it is determined that the narcotic count is incorrect?

8 :
Which type of lubricant should the nurse use to administer a rectal suppository?

9 :
The nurse is preparing an anxious client for major surgery and remarks, "Everyone feels some anxiety, but you will be asleep during the whole thing and it will be fine." This is an example of which communication style?

10 :
A nurse is conducting an interview with a client to collect a medication history. Which of the following questions would be most important to ensure safe medication administration?

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Communication, Pharmacology, Tissue Integrity Exam 2

No.

1 : In assessing the skin condition of an elderly client, the nurse notes that, over the sacral area, there is a 2-cm to 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

2 : A 2-year-old child is hospitalized with tonsillitis and bilateral otitis media. The nurse is preparing to administer prescribed ear drops. When instilling the medication, the nurse should pull the child's earlobe?

3 : The nurse is talking a verb order for a new medication. Which is the most accurate and safest way for the nurse to transcribe an order for a two milligram dose into the client's chart?

4 : A nurse is preparing to administer iron, a medication that has the potential to stain the skin. Which of the following should the nurse do?

5 : The pediatric nurse knows the most accurate medication dosage for a child is determined by using which piece of assessment data:

6 : Which of the following examples best demonstrates safe drug administration by the nurse?

7 : Which action will the nurse take when it is determined that the narcotic count is incorrect?

8 : Which type of lubricant should the nurse use to administer a rectal suppository?

9 : The nurse is preparing an anxious client for major surgery and remarks, "Everyone feels some anxiety, but you will be asleep during the whole thing and it will be fine." This is an example of which communication style?

10 : A nurse is conducting an interview with a client to collect a medication history. Which of the following questions would be most important to ensure safe medication administration?

1 :
In assessing the skin condition of an elderly client, the nurse notes that, over the sacral area, there is a 2-cm to 3-cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:

2 :
A 2-year-old child is hospitalized with tonsillitis and bilateral otitis media. The nurse is preparing to administer prescribed ear drops. When instilling the medication, the nurse should pull the child's earlobe?

3 :
The nurse is talking a verb order for a new medication. Which is the most accurate and safest way for the nurse to transcribe an order for a two milligram dose into the client's chart?

4 :
A nurse is preparing to administer iron, a medication that has the potential to stain the skin. Which of the following should the nurse do?

5 :
The pediatric nurse knows the most accurate medication dosage for a child is determined by using which piece of assessment data:

6 :
Which of the following examples best demonstrates safe drug administration by the nurse?

7 :
Which action will the nurse take when it is determined that the narcotic count is incorrect?

8 :
Which type of lubricant should the nurse use to administer a rectal suppository?

9 :
The nurse is preparing an anxious client for major surgery and remarks, "Everyone feels some anxiety, but you will be asleep during the whole thing and it will be fine." This is an example of which communication style?

10 :
A nurse is conducting an interview with a client to collect a medication history. Which of the following questions would be most important to ensure safe medication administration?