The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

Scrub the stem of the ampule with antimicrobial wipe.

Break the stem of the ampule away from the body

Attach a filter needle to the syringe.

Tap the stem of the ampule.

Wrap the stem of the ampule with a sterile gauze pad.

Answer and Explanation

Correct Answer : B,C,E

A. Scrub the stem of the ampule with an antimicrobial wipe. This is not necessary because the stem of the ampule is broken and is not typically touched with hands or contaminated. The main concern is to prevent any glass from falling into the medication.

B. Break the stem of the ampule away from the body. Breaking the stem away from the body helps to prevent any shards of glass from falling into the medication or causing injury.

C. Attach a filter needle to the syringe. A filter needle is used to prevent any glass particles from entering the syringe when drawing up the medication from an ampule.

D. Tap the stem of the ampule. Tapping the stem may help remove any bubbles but is not a standard practice in ampule preparation.

E. Wrap the stem of the ampule with a sterile gauze pad. Wrapping the stem with a sterile gauze pad provides protection from glass shards and helps prevent injury when breaking the ampule.

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Correct Answer is A

Explanation

A. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.

B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.

C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.

D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.

A. "I can tell your family not to visit you close to bedtime." B. "Would you like me to provide you with earplugs?" C. "I can get you a mental health consult if you think that would help." D. "Tell me why you think you may not be sleeping at night."

Correct Answer is D

Explanation

A. "I can tell your family not to visit you close to bedtime." While this could be a consideration, it does not address the patient's immediate concerns and the possible causes of their sleep issues.

B. "Would you like me to provide you with earplugs?" This is a possible solution but does not investigate the underlying cause of the sleep issue.

C. "I can get you a mental health consult if you think that would help." A mental health consult may be helpful, but it is not the first step in understanding and addressing the immediate concern.

D. "Tell me why you think you may not be sleeping at night." This is the best initial response as it allows the nurse to understand the root cause of the patient's sleep disturbances and address specific issues, such as noise, light, or discomfort.

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The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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