ATI proctored final exam

How can an RN delegate surgical aesepsis responsibilities to UAP's?

As the circulating nurse, the RN can have UAPs under her supervision involved in activities requiring surgical asepsis. On the unit, situations requiring surgical asepsis are not delegated to UAP.

How can an RN delegate transmission-based precaution responsibilities to UAP's?

The RN can delegate care of a client requiring precautions to UAP. The nurse cannot delegate the assessment of need for precautions, evaluation of effectiveness of client compliance with precautions, or teaching of client & family member's precaution techniques. The nurse delegating care of an isolated client should be sure the UAP knows appropriate procedures.

When should traditional hand washing be used instead of using alcohol-based sanitizer?

When hands are visibly soiled
After touching bodily fluids
Before and after applying sterile gloves
After using sanitizer 10 or more times

Contradictions of good hand hygiene

Nail polish
Long nails
Using lotions
Wearing jewelry

Which of the following is a potential route of entry into the body for bloodborne pathogens:
a. Mucous membranes
b. Puncture wounds
c. Burns on hands
d. Blood
e. All of the above

E. All of the above

Personal Protective Equipment is the single most effective way to prevent the transmission of infection. (TRUE or FALSE)

True

Two potential sites for nosocomial infections:

1. A hospital
2. Homecare

Potential causes of nosocomial infections:

1. Pt has suppressed immune system
2. Failure to follow isolation precautions or aseptic technique
3. Hospital error

You are assisting in the evaluation of a pt with acute onset of severe headache, fever and some confusion. The physician is preparing to perform a lumbar puncture. The suspected diagnosis is bacterial meningitis. What type of precaution is needed?

Standard precautions

A 70 y. male develops new diarrhea and a high WBC while in the hospital recovering from MV Replacement surgery which was complicated by a CVA. He is bed bound and incontinent of stool. What do you suspect is the cause for his diarrhea?

A bacterial, nosocomial infection

Medical abbreviation: CBR, BR

complete bedrest, bedrest

T/F: Frequent bathing for the older client is necessary to prevent skin breakdown.

False

A ____ bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation.

sitz

List at least three guidelines for providing patient-centered care when addressing a client's hygiene needs

Be respectful to cultural values.
Ask the pt in what order they would like to complete their hygiene routine.
Provide hygienic care as often as necessary (but not too often) and as gently as necessary.

What should be included in documentation of a bath?

Date and time
Type of bath
Abnormal findings/pt reaction

When might the RN need to collaborate a colleague for personal care?

If a patient is not ambulatory and is too heavy to be moved alone

What are the components of the Braden scale?
Is a high score good or bad?

Sensory perception, moisture, activity, mobility, nutrition, friction & shear
High score indicates low risk.

Trochanter roll

Keeps hips in a neutral position

Hemiparesis

Weakness on one sign of the body

Hemiplegia

Paralysis on one side of the body

Prone position

Lying on the abdomen

Sim's position

Lying on left side w/ left leg straight and right knee bent

Foot drop

Gait w/ drop of the forefoot

Fracture pan

A bedpan used for someone w/ a hip fracture

Fecal impaction

Dry, hard stool stuck in the rectum

Hand roll

Hand placed in the palm to prevent fractures

Medical abbreviation: WNL

Within normal limits

Medical abbreviation: BRP

bathroom privileges

Medical abbreviation: BUS

Bladder ultrasonic scanner

Factors to consider when delegating to UAP

Scope of practice
Facility, state regulations
Level of experience
Pt safety

Hazards of immobility on CV system & interventions

DVT: elastic stockings, SCD's
Orthostatic BP: give pt time btwn position changes

Hazards of immobility on pulmonary system & interventions

PE: TED host
Inadequate expansion of the chest: place pt in orthopneic position
Pneumonia: clean/sterile technique, pneumovax

Intervention for each: early and frequent ambulation

Hazards of immobility on renal system & interventions

UTI, problems with continence, altered BP: monitor I/O's, assist w/ voiding as needed

Hazards of immobility on integumentary system & interventions

Skin breakdown: repositioning, monitor nutrition status, reduce mositure, provide hygiene care

Hazards of immobility on musculoskeletal system & interventions

Stiff joints: ROMs/ambulation
Muscle atrophy: ROMs/ambulation
Ca2+ imbalance: nutrition measures

Risk factors for skin breakdown

Poor nutrition, bedrest, obesity, old again, using an SPM machine, increased friction and shear

List at least 4 areas prone to skin breakdown

1. Tailbone
2. Heels
3. Elbows
4. Hips

What nursing intervention would be most effective in preventing flaccidity in a hospitalized patient?
a. Early ambulation after surgery
b. Administering calcium with vitamin D
c. Coughing and deep breathing exercises
d. Referring the patient to occupational therapy

A. Early ambulation after surgery

After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation?
a.Warmth of bilateral upper extremities
b. Lower extremity circulatory status
c. Circumoral cyanosis
d. Bowel sounds

b. Lower extremity circulatory status

Components of Morse Fall Scale

History of falls, secondary diagnosis, ambulatory aid, IV/hep lock, gait/transferring, mental status
Scores:
45+ = high risk
25-44 = moderate risk
0-24 = low risk

ID injections (TB syringes)

Max amt: 0.1 cc
Usual site: forearm
Angle: 15-20 degrees
Length: 1/4 - 1/2 in
Aspiration? No

SQ injections

Max amt: 2 cc
Usual site: Upper arm, stomach
Angle: 45 degrees
Length: 1/2 - 1 in
Aspiration? Yes

IM injections

Max amt: 5 cc
Usual site: deltoid (1 cc), gluteus med/max or vastus lateralis (5 cc)
Angle: 90 degrees
Length: 1 - 1.5 in
Aspiration? Yes

Explain how to draw a combined dose of two types of insulin

1. Inject NPH vial w/ air
2. Inject regular vial 1/ air
3. Draw regular insulin
4. Draw NPH insulin

What factors affect a BG result?

Having fasted or eaten, time of day, level of activity, stress, illness, menstruation

When is a client most at risk for hypoglycemia?

In the morning before breakfast

What are considerations for pt's on blood thinners such as warfarin, asprin, heparin, coumadin, etc?

Monitor platelet levels (labs)
Watch for bleeding/reduce risks of bleeding
Monitor vitals (esp. BP)
Assess skin
Monitor mobility status

Is it okay to give benzodiazopans to older adults?

No, benzo's increase the risk of accidents and mental deficits

Medical abbreviation: FUO

fever of unknown origin

Medical abbreviation: qhs

at bedtime

Medical abbreviation: ac

before meals

What are contraindications for opening capsules and mixing with food?

EC: enteric coated
ER: extended release

Rapid acting insulin

Generic & brand names: Inslin aspart (NovoLog), insulin glulisine (Apidra), insulin lispro (Humalog)
Onset: 15 min
Peak: 30 - 90 min
Duration: 3-5 hr

Short acting insulin

Generic & brand names: Inslin regular (Humulin R, Novolin R)
Onset: 30 - 60 min
Peak: 2 - 4 hr
Duration: 5 - 8 hr

Intermediate-acting insulin

Generic & brand names: Insulin NPH (Humulin/Novolin N)
Onset: 1 - 3 hr
Peak: 8 hr
Duration: 12 - 16 hr

Long-acting insulin

Generic & brand names: insulin glargine (lantus), insulin detemir (levemir)
Onset: 1 hr
Peak: no clear peak
Duration: 20 - 26 hr

Signs of infiltration

Edema, pallor, decreased skin temperature around the site, and pain

Signs of phlebitis

Pain, increased skin temperature, and redness along the vein

Signs of extravasation (infiltration w/ dislodged IV catheter)

Pain, stinging or burning at the site, swelling, and redness

Nursing interventions for infiltration, phlebitis, and extravasation

Infiltration: D/C IV, elevate extremity, apply warm compress
Phlebitis: D/C IV, apply warm/moist compress
Extravasation: D/C IV, apply cool compress, administer antidote if needed, document degree of extravasation

Medical abbreviation: INT

intermittent (catheter)

The 6 rights of medication administration

1. Right drug
2. Right dose
3. Right route
4. Right pt
5. Right time
6. Right documentation

List at least 3 nursing interventions r/t routine care of peripheral iV

1. Check insertion site frequently
2. Change tubing every 96 hr
3. Use good hand hygiene + standard precautions

Factors to consider when choosing the best IV location

Age, condition of veins, circulation status, length of IV therapy

What is the smallest gauge IV catheter used to infuse blood?

20-22: RBS' might get crushed when using a smaller catheter

4 techniques to improve the chances of good IV access

1. Trim hair around the area
2. Gently stroke the area from the distal to proximal end
3. Place a warm blanket over the extremity
4. Palpate gently

At what range of rate should you administer maintenance fluids?

~75-150

Does the secondary/piggyback IV bag hang above or below the primary bag?

Below (use blue hook)

What gauge catheters should you use for IV access?

24: children
22: older adults (esp women)
20: healthy adult
16-18: trauma pt's

What is included in an IV start kit?

Tourniquet, alcohol wipe, gauze, tape

Will also need: IV catheter, saline flushes, extension tubing

Cardiac tamponade

Fluid in the pericardial sac

Tunneled catheter

A catheter surgically inserted into a trench

Delegation: central lines

Care/dressing changes cannot be delegated to UAP.
UAP may observe central lines and report concerns.

What are PICC lines used for? Where are they inserted?

Used for long-term IV access

Inserted in the basilica or cephalic vein just above or below the antecubital space, resting in the superior vena cava

What are multi lumen central catheters used for?

Monitoring central venous pressure ,sampling blood, and simultaneous administration of multiple IV solutions/drugs

Hickman catheter

Used for chemotherapy or blood withdrawal

List nursing interventions associated w/ routine care of a central IV

1. Clamp the central line when not in use
2. Maintain patency by flushing
3. Avoid excessive force w/ small syringes
4. Never use a syringe smaller than 10 mL

List potential central IV complications and nursing interventions associated w/ each

1. Infection: hand hygiene, scrub the hub, use aseptic technique
2. Pneumothorax: monitor vitals, admin O2 if needed, notify the provider of warning signs
3. Air embolism: check the line frequently, keep catheters clamped, don't inject air; if embolism occurs: clamp catheter, admin O2, and place pt of left side in Trendelenberg (supine w/ feet elevated)

Which activity is important to include in the plan of care for a client with a PICC?
a. Use sterile technique when changing the PICC dressing.
b. Change the IV tubing every 72 hours.
c. Take blood pressure in the arm with the PICC line.
d. Use only macrodrip tubing with IV infusions through the PICC line.

A. Use sterile technique when changing the PICC dressing

Medical abbreviation: UA for C&S

urinary analysis for culture & sensitivity

What are two ways the nurse may obtain a C&S?

Sterile collection from Foley
Sterile collection from straight cath

Client instructions for stool for occult blood specimen

Collection 3 walnut-sized feces samples
Avoid asprin, steroids, beets, poultry, red meat, and seafood

Client instructions for 24 urine collection

Collect urine for a period of 24 hr after first full void
Refrigerate each sample

Client instructions for midstream urine collection

Clean the peritoneal area
Collect a midstream sample after urinating for several seconds

What color does a fecal sample containing occult blood turn?

Blue

A UA that is positive for hemoglobin, WBCs, and nitrites indicates:

UTI

Differentiate implications for utilizing intermittent versus indwelling urinary catheterization.

Intermittent is less uncomfortable for the patient and has a lower risk of infection. It should be used in kids.

Describe at least 3 strategies for preventing UTI in the client after insertion of an indwelling catheter.

Provide peritoneal care every 6 hours
Change out the catheter every 8 hours
Drain the collection bag PRN (when full and before ambulation)
Remove the Foley post-op day 2
Maintain adequate fluid intake

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform?
a. Check to see if the catheter is patent.
b. Reassure the patient that it is not possible to void while catheterized.
c. Catheterize the patient again with a larger-gauge catheter.
d. Notify the primary care provider (PCP).

A. Check potency using 2 10 mL saline flushes

Medical abbreviation: LIWS

Low intermittent wall suction

Contraindications for an NG/OG tube

Obstruction, tube already inserted, recent facial surgery, bleeding contraindications

Your pt has a PEG tube that was inserted 2 days ago. As you are preparing your pt's morning medications, you are unable to flush the tube with sterile water. Give 2 examples of nursing interventions to manage this problem.

Check to see if the tubing is clamped. Check the tubing for clogs. Push in air. Try to unclog w/ warm water. Get order for enzyme.

Your pt is receiving TPN. What are some potential complications related to administration of TPN? Give examples of nursing interventions necessary to prevent complications related to administration of TPN.

(See Yoost pg 693)
Skin breakdown/irritation: assess frequently, provide adequate hygiene care
Air embolism: be careful about administering solutions in the wrong line

You are an RN who is inserting an NG tube for decompression. Your pt begins to gag. Give 3 examples of nursing interventions to manage your pt's response.

Stop pushing and slow down insertion. Tilt pt's chin toward chest. Check the mouth for substances to prevent aspiration. Continue advancing the tube btwn breaths.

What specific laboratory values should be monitored for patients requiring continuous enteral feeding?

Electrolyte levels, glucose levels

Your patient will be discharged home with a PEG tube. The need for dietary education and nutritional planning is important once the pt goes home. Give examples of questions that may need to be considered prior to your pt discharge.

Ability to clean the dressing and insert feedings properly, knowledge of what to do if complications arise

Hydrocolloid dressing

Opaque, biodegradable, non-breathable, adherent dressing

Penrose drain

A surgical fluid drain

Calcium alginate

Gel used to entrap enzymes during wound healing