Foundations Exam 2

When do the three medication checks take place?

1. At the Pyxis

2. Preparing for administration

3. Scanning medications

How many times should you compare the label of the medication to the MAR?

Three

Which medications should be double checked with another RN before administration?

High alert meds

Should medications given via GT/NG tubes be given together or separately?

Separately

Where should a patient be positioned to administer rectal medications?

Lateral on left side

Where are eye drops placed?

Lower conjunctival sac

How should a nurse manipulate an adult's ear to administer ear drops?

Pull up and out

How should a nurse manipulate a child's ear to administer ear drops?

Pull down and back

What is the appropriate needle gauge for a sub Q injection?

25-28 gauge

What are the appropriate locations of a sub Q injection?

Arms, back, thighs, buttocks, abdomen

What is the appropriate needle length for a sub Q injection?

5/8" - 1/2"

What is the maximum dosage amount for a sub Q injection?

1 mL

What is the appropriate needle length for an IM injection in the deltoid?

1" (1" and 1mL for deltoid)

What is the appropriate needle length for an IM injection in the glute or thigh?

1"-3"

What is the maximum dose for an IM injection in the deltoid?

1mL (1" and 1mL for deltoid)

What is the appropriate needle gauge for an IM injection?

18-23 gauge

How do the lungs contribute to fluid mediation?

Expel moisture with exhalation - insensible water loss

What are the major implications of Na+ changes in the body?

Neurological changes

Which electrolyte must never be administered via IV push?

Potassium

What body systems does potassium primarily impact?

Cardiac and musculoskeletal

How does calcium impact the cardiac and musculoskeletal systems?

Regulates contractions

What two electrolytes should a nurse immediately check if a patient reports heart palpitations?

Calcium and potassium

Which measurement is the most sensitive for measuring fluid status?

Daily weights

What are some of the clinical manifestations of fluid volume deficit?

Decreased urine output, tachycardia, orthostatic hypotension, elevated temp, thready pulses

What hourly urine output should a nurse expect for a patient on effective IV fluid replacement therapy?

50 mL/hour

Which fluids are isotonic?

0.9% NaCl (normal saline)

Lactated Ringers

5% Dextrose in water (D5W)

Which fluids are hypotonic?

0.45% NaCl

Which fluids are hypertonic?

3.0% NaCl

10-15% Dextrose in water (D10W, D15W)

How would administering hypertonic fluids impact the body?

Pull fluid back into the vascular space

Which fluids are administered via the primary tubing, and which are administered via the secondary (piggyback) tubing?

Primary: maintenance fluids

Secondary: frequent medications

How often must IV bags be changed?

q24 hrs

How often must central line IV tubing be changed?

q24 hrs

How often must peripheral IV tubing be changed?

q72-96 hrs

Is a patient at greater or lesser risk of transfusion reactions with the more transfusions they receive?

Greater risk - more antigen exposures

What value should increase if a patient receives packed RBCs? By how much?

Hematocrit (Hct) by 4% max

When should a nurse take a patient's vital signs during a blood transfusion?

1. Before administration

2. 15 minutes after the infusion begins

3. Every hour (if first two checks are normal)

4. After completion

What fluids are administered with blood transfusions?

ONLY normal saline

A patient receives an order for a blood transfusion. What is the nurse's priority action?

Check for a blood transfusion consent form

What is the most common transfusion reaction?

Febrile

What are the first symptoms of a hemolytic transfusion reaction? What causes these symptoms?

Low back pain caused by the kidneys being clogged with broken down (post-attack) RBCs

What is the priority concern for a patient experiencing an allergic reaction to a transfusion?

Maintaining an airway

What is the priority nursing action if the patient experiences any transfusion reaction?

Stop the transfusion and notify provider

Where does edema occur?

Interstitial space of tissues

Where does ascites occur?

Peritoneal cavity

What are some of the clinical manifestations of fluid volume excess? Which is most dangerous?

Edema, pulmonary edema (most dangerous), jugular vein distension (JVD)

What should be considered during a nutrition assessment?

Food allergies

Problems chewing/swallowing

Dentures

Diet restrictions (diabetic, cardiac, etc.)

Religious/cultural restrictions

Vegetarian/vegan

Describe a cardiac diet.

Low fat, low sodium

Describe a renal diet.

Restricts Na, P, K, fluid, protein

Describe a diabetic diet.

High fiber, little/no sugar

List some aspiration precausions.

Liquid thickness

Sitting up to eat

Small bites

Oral care before and after

How should the placement of an NG tube be verified?

X ray

Aspirate - contents should have a pH

How much water should a nurse flush a feeding tube with?

30 mL

How often should a nurse measure gastric residual volumes?

Every 4-6 hours

List some risk factors for impaired skin integrity.

Immobility

Poor nutrition

Fecal/urinary incontinence

Diminished sensation

Altered mental status

Advanced age

A patient has an area of intact skin with non-blanchable redness. What stage pressure injury is this?

Stage 1

A patient has an area with partial thickness loss of dermis, which presents as a shallow, open ulcer. What stage pressure injury is this?

Stage 2

A patient has an area with visible subcutaneous tissue (but no bone, tendons, or muscle). What stage pressure injury is this?

Stage 3

A patient has an area with full thickness tissue loss with visible bone, tendon, and muscle. What stage pressure injury is this?

Stage 4

What would make a pressure injury unstageable?

Base of the injury covered by slough or eschar

A patient has an area of purple or maroon skin, which is intact. What type of injury is this?

Deep tissue injury

What are the three stages of wound healing? How long does each last?

1. Inflammation: 4-6 days

2. Proliferation: 4-24 days

3. Remodeling: 21 days - 2 years

A patient has a surgical incision that has been approximated and sutured. What type of healing will this wound likely exhibit?

Primary intention

A wound fills with a large clot that is eventually replaced by granulation tissue and a large scar. What type of healing did this wound exhibit?

Secondary intention

A contaminated wound fills with granulation tissue with a large fissure. What type of wound healing is this?

Tertiary intention

Which vitamins promote wound healing?

Vitamins A and C

How does limiting edema help a wound heal?

Wound edges cannot approximate if the swelling is severe

Why must necrotic tissue be removed to allow for wound healing?

Necrotic tissue prevents granulation tissue from forming.

What is the primary nursing consideration for a dry wound?

Hydrate the wound

What is the primary nursing consideration for a wet wound?

Absorb exudate

What is the primary nursing consideration for a shallow wound?

Cover the wound

What is the primary nursing consideration for a deep wound?

Pack the wound

What are some observations about a wound that should be included in documentation?

Base description

Drainage

Edges

Odor

Pain

Progress

Location

Stage

Dimensions

Tunneling

What is the difference between a tracheotomy and tracheostomy?

Tracheotomy is the procedure of creating an opening for the trach, tracheostomy is the hole that is created (stomy=stoma)

What are the priority considerations for air entering a trach tube?

Must be humidified and at the appropriate temperature since it bypasses the nose and mouth

What is the primary purpose of suctioning the trach?

Maintain a clear airway for patients who cannot cough out secretions

What are the potential complications of suctioning a tracheotomy?

Hypoxia

Tissue trauma

Vagal stimulation

Cardiac dysrthythmias

What is the name of the device that is used to help insert a tracheotomy if it becomes removed or needs to be changed?

Obturator

What should a nurse keep in the room for a patient with a tracheotomy?

Obturator

Same size trach and one smaller

Inner canula

Suction

Sterile water

Suction catheters and yankauer

Sterile gloves

Ambu bag

Humidification

How many nurses should be in the room when providing trach care? Why?

Two - one holds trach in place to prevent decannulation

What must never be used in a room with oxygen?

Oil or alcohol based products (other than hand sanitizer) or open flames.

A patient wants to apply petroleum jelly on their nose to help with pressure injuries from their nasal canula. Is this allowed?

No - petroleum jelly is oil-based

What is tracheomalacia?

Weakening of the tracheal cartilage that causes the trachea to collapse when breathing out

What should a nurse do directly before suctioning a trach?

Hyperoxygenate the patient

How often must a central line dressing be changed?

Every 7 days

What must the patient and nurse wear when cleaning a central line?

Masks

What must also be changed when a nurse changes a central line dressing?

Injection caps

A patient is experiencing labored breathing/shortness of breath. What is this called?

Dyspnea

A patient is experiencing shortness of breath when they change positions. What is this called?

Orthopnea

What are bronchovesicular sounds?

The sounds of air moving through bronchial tubes and open lung fields

What are vesicular sounds?

Soft blowing sounds in the open areas of the lungs near the alveoli

What conditions are associated with crackles?

Pneumonia, COPD (fine), pulmonary edema (course)

What causes rhonchi?

Secretions in the large airways

What causes stridor?

Severe obstructions of the upper airways

What conditions cause wheezing?

COPD, asthma (tightening of lower airways)

What are some nursing teachings that promote proper breathing?

Teaching deep breathing

Use of incentive spirometer

Teaching pursed-lip breathing

Teaching diaphragmatic breathing

In what position should an unsecured oxygen tank be placed?

On its side (only upright and unattended if secured)

What levels can a nasal canula be set to?

2-6L

What must be added to oxygen in a nasal canula if the rate is greater than 4lpm?

Moisture

When are low flow oxygen systems used?

When the patient can meet some of their inspiratory needs by inhaling both the oxygen and some room air

When are high flow oxygen systems used?

When the patient does cannot meet an adequate inspiratory rate or tidal volume