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 D

Explanation

A. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.

B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.

C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.

D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.

A. "Addressing organ donation and autopsy issues." B. "Naming a durable power of attorney for my health care needs." C. "Addressing who gets my personal items if I should die." D. "Naming which life sustaining treatments, I want and do not want."

Correct Answer is ["B","D"]

Explanation

A. "Addressing organ donation and autopsy issues." Advanced directives typically address preferences about medical treatment and end-of-life care, but organ donation and autopsy decisions are not always included in these directives. Organ donation often involves a separate document or registration.

B. "Naming a durable power of attorney for my health care needs." An advanced directive often includes designating a durable power of attorney (DPOA) for healthcare decisions. This person is authorized to make medical decisions on the patient’s behalf if they become unable to do so themselves.

C. "Addressing who gets my personal items if I should die." The distribution of personal items is typically covered in a will, not an advanced directive. Advanced directives focus on healthcare decisions rather than the distribution of personal property.

D. "Naming which life-sustaining treatments I want and do not want." Advanced directives often include instructions about specific medical treatments and interventions that the patient does or does not want, such as resuscitation, mechanical ventilation, or tube feeding.

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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

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Explanation

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Explanation

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