Advanced Skills Objective Exam Flashcards
0
Q
How often should you assess the patient for tube patency?
A
At least hourly
1
Q
What are some indicators of tube obstruction?
A
Difficulty breathing, noisy respirations, thick dry secretions, and unexplained peak pressures
2
Q
True or false
Tube dislodgment in the first 72 hours is an emergency because the tracheostomy tract has not matured and replacement is difficult
A
True
3
Q
What is pneumothorax?
A
Pneumothorax (air in the chest cavity) can develop during the tracheostomy procedure if the chest cavity is entered. When pneumothorax occurs during tracheostomy, it usually does so at the apex of the lung. Chest xrays after placement are used to assess for pneumothorax
4
Q
When does subcutaneous emphysema occur?
A
Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into fresh tissue planes of the neck.
5
Q
What causes Tracheomalacia?
A
Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage.
Manifestations: an increased amount of air is required in the cuff to maintain the seal, larger trach tube is needed to prevent air leak, patient does not receive set tidal volume on the ventilator
6
Q
What causes Tracheal Stenosis?
A
Narrowed tracheal lumen is due to scar formation from irritation of tracheal mucosa by the cuff
Manifestations: patient has increased coughing, inability to expectorate secretions
7
Q
What causes a Trachea-innominate artery fistula?
A
A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery.
Manifestations: Heavy bleeding from stoma, this is a life threatening complication/medical emergency
8
Q
What causes a Tracheoesophageal fistual?
A
Excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the tracheas and the anterior esophagus.
Manifestations: Similar to tracheomalacia
9
Q
What type of technique should you use when providing trach care?
A
Sterile technique
10
Q
How often after trach surgery should you provide cannula care?
A
Every 30-60 min for the first 24 hours
11
Q
What are some complications suctioning can cause?
A
Hypoxia, tissue trauma, infection, vagal stimulation, bronchospasm, and cardiac dysrhythmias
12
Q
How is hypoxia caused and how can it be prevented?
A
Hypoxia causes:
- Ineffective oxygenation before and after suctioning
- Prolonged suctioning
- Too frequent suctioning
- Excessive suctioning pressure
- Too large of catheter
Hypoxia can be prevented by hyper-oxygenating a patient and using a 12-14 FR catheter on adults
13
Q
How long should you suction for?
A
10-15 seconds
14
Q
Vagal stimulation during suctioning
A
Vagal stimulation results in severe bradycardia, hypotension, heart block, ventricular tachycardia, a-systole or dysrhythmias. If vagal stimulation occurs stop suctioning immediately and oxygenate patient manually with 100% O2
15
Q
How often should you turn and reposition a trach patient?
A
every 1-2 hours
16
Q
What should you avoid using when providing oral care?
A
Avoid using glycerin swabs or mouthwash that contains alcohol to clean the mouth because these products dry the mouth, change its pH, and promote bacterial growth.
17
Q
When is a trach patient able to speak?
A
The patient can speak when there is a cuff less tube, when a fenestrated trach tube is in place, and when the fenestrated tube is capped or covered
18
Q
_______is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation and erosion of cartilage
A
Tracheomalacia
19
Q
A patient has an inflated cuffed #8 shiley tracheostomy and is on a ventilator. The tracheostomy tube is pulsating in synchrony with the patients heartbeat. What does the nurse do first?
A
Notify the physician of the pulsating tube
20
Q
A patient requires long term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session?
A
Tracheostomy tube
21
Q
A patient is receiving preoperative teaching for a partial larynectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient?
A
Opening in the trachea that enables breathing
22
Q
A patient returns from the operating room and the nurse assesses for subcutaneous emphysema which is a potential complication associated with tracheostomy. How does the nurse assess for this complication?
A
Inspecting and palpating for air under the skin
23
Q
A patient with a tracheostomy without a tube in place develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to?
A
Tracheal stenosis
24
A patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the physician?
Skin is puffy at the neck area with a crackling sensation
25
A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing intervention is NOT appropriate for this patient?
Suction the airway with oral suction equipment
26
To prevent accidental decannulation of a tracheostomy tube, what does the nurse do ?
Secure the tube in place using ties or fabric fasteners
27
A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside?
1. Ambu bag
2. Oxygen tubing
3. Suction equipment
4. Tracheostomy tube with obturator
28
Which statement by the nursing student indicates an understanding of the deflation of the tracheostomy cuff?
The cuff is deflated to allow the patient to speak
29
A patient has a temporary tracheostomy following surgery to the neck areas to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube?
Provide tracheal suctioning when there are noisy respirations
30
A patient sustained a serious crush injury to the neck and had a trach tube placed yesterday. As the nurse performing trach care, the patient suddenly sneezes very forcefully and the trach tube falls out. What does the nurse do?
Quickly and gently replace the tube with a clean cannula kept at the bedside
31
A patient with a tracheostomy or endotracheal tube has inline suctioning. Which nursing interventions apply to proper suctioning technique?
1. Oxygenate the patient before suctioning
2. Instruct the patient that they will be suctioned
3. Suctioning ti,me is the same for trach and endotrach
4. The suction tubing is locked after suctioning is completed
32
What are possible complications that can occur with suctioning from an artificial airway?
!. Infection
2. Hypoxia
3. Tissue trauma
4. Vagal stimulation
5. Bronchospasm
6. Cardiac dysrhythmias
33
A patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this patient?
It helps prevent tracheal damage
34
A patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning?
Hypoxia
35
Indicate the correct steps of completing a suctioning procedure
1. Open the suction kit
2. Pour sterile saline into sterile container
3. Put on sterile gloves
4. Keep catheter sterile, attach to suction
5. Lubricate catheter tip in sterile saline
6. Preoxygenate the patient
7. Insert catheter into trahcea without suctioning
8. Withdraw catheter, applying suction and twirling catheter
9. Discard supplies, wash hands, document
36
Indicate the correct steps of performing tracheostomy care
1. Suction trach tube if necessary
2. Remove old dressing and excess secretions
3. Open tracheostomy kit and pour peroxide into one side of the container and saline into another
4. Put on sterile gloves
5. Remove inner cannula, place in peroxide solution and clean
6. Rinse inner cannula in saline
7. Reinsert inner cannula into outer cannula
8. Clean stoma site and plate
9. Change trach ties
10. Wash hands, dispose of equipment
37
While the nursing student changes a patients tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4X4 gauze pad to make a split dressing fit around the trach tube. What is the nurses best action?
Direct the student in the correct use of materials and explain rationale
38
The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU, but he had no unusual occurrences related to the tracheostomy or his O2 status. What does routine care for this patient include?
Thorough respiratory assessment every 2 hours
39
A patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do ?
Increase the humidity in the home
40
A patient with a permanent tracheostomy is interested in developing an exercise regimen. What activity does the nurse advise the patient to avoid?
Swimming
41
A patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care?
Uses toothettes or a soft bristled brush moistened in water
42
A patient with a tracheostomy who receives unnecessary suctioning can experience which complications?
1. Bronchospasm
2. Mucosal damage
3. Bleeding
43
A patient with a tracheostomy tube is able to speak and is no longer on mechanical ventilation. Which type of trach tube does this patient have?
Fenestrated tube with inner cannula removed and the red stoppper locked in place. Size #6 shiley deflated cuffed that is capped
44
What is a talking tracheostomy tube?
Used with patients who can speak while on a ventilator for a long term basis
45
What is a cuffed tube?
Has a cuff that seals the airway when inflated
46
What is a cuffless tube?
Used for long term management of patients not on mechanical ventilation or at high risk for aspiration
47
What is a double lumen tube?
It has 3 parts; outer cannula, inner cannula, and obturator
48
What is a metal tracheostomy tube?
Used for permanent tracheostomy
49
What is a cuffed fenestrated tube?
Used often with patients with spinal cord paralysis or muscular disease who do not require a ventilator all the time
50
What is a single lumen tube?
Has no inner cannula and is used for patients with long or extra thick necks
51
What is a fenestrated tube?
Used when weaning a patient from a ventilator, allows patient to speak
52
A patient has a cuffed trach tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?
Assess and record cuff pressure each shift using minimal leak technique
53
An older adult patient is at risk for aspirating food or fluids. Which are the most appropriate nursing actions to prevent this problem?
1. Provide close supervision if the patient is self feeding
2. Instruct the patient to tuck the chin down when swallowing
3. Place the patient in an upright position
54
an older adult sustained a stroke several weeks ago and is having difficulty swallowing. To prevent aspiration during meal times, what does the nurse do?
Encourage dry swallowing after each bite to clear residue from the throat
55
A patient with a trach tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?
Avoid prolonged suctioning time
56
The nurse is suctioning from patients endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54 and a drop in blood pressure to 90/50. after stopping suctioning, what is the nurses priority action?
oxygenate with 100% oxygen and monitor the patient.
57
a patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse.Which nursing intervention is the best approach in this situation?
Ask questions that can be answered with a yes or no response.
58
Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention?
Pulsating tracheostomy tube in synchrony with the heartbeat.
59
The nurse is providing discharge instructions for a patient who must perform self care tracheostomy. The patient has been cheerful and cooperative during the hospital stay and has demonstrated interest and capability in performing self care but now the patient begins crying and refuses to leave the hospital. What is the nurses response?
You have been brave and cheerful, but there is something that is worrying you.
60
What nursing action will limit hypoxia when suctioning a clients airway?
Applying suction only after the catheter is inserted
61
Which nursing action is important when suctioning the secretions of a client with a tracheostomy?
Initiating suction as a catheter is being withdrawn
62
Where is a chest tube place?
The tip of the tube used to drain air is placed near the front lung apex. The tube that drains liquid is placed on the side near the base of the lung.
63
True or false
Stationary chest tube drainage systems usually use a waterseal mechanism that acts as a one-way valve to prevent air or liquid for moving back into the chest cavity
True
64
What is the Pleur-evac system?
It's a common device using a one piece disposable plastic unit with three chambers. The three chambers are connected to one another. The first chamber is the drainage collection container. The second chamber is the water seal to prevent air from moving back up the tubing system and into the chest. The third chamber, one suction is applied, if the suction regulator.
65
True or false
| Chamber 2 must always contain 2 cm of water to prevent air from returning to the patient
True
66
What does the bubbling of the water in the water seal chamber indicate?
It indicates air drainage from the patient. Bubbling is usually see when intrathoracic pressure is greater than atmospheric pressure, such as when the patient exhaled, coughs, sneezes.
67
Which chamber is the suction control of the system?
Chamber 3
68
True or false
| Notified the physician of drainage if more than 100 mL an hour occurs
True
69
What are some complications of a pneumonectomy?
Emphysema (purulent material in the pleural space) and....
70
Describe a waterseal chamber
1. It prevents atmospheric air from entering plural space
2. Fluid level fluctuates with respirations until long is fully expanded
3. Continuous bubbling may indicate air leak
4. Requires installation of sterile water to 2 cm level one being set up for use
71
Describe a suction control chamber
1. Controls amount of suction
2. Requires installation of sterile fluid usually 20 cm level
3. Steady bubbling indicates suction level is maintained
72
Describe a dry suction waterseal drainage system
1. It has three chambers like a waterseal drainage but does not require fluid in suction control chamber
2. Quieter than traditional waterseal drainage
73
Describe a one-way valve system
1. It's used to remove Air and small amounts of fluid from pleural space
2. The valve prevents air from reentering pleural space
74
What is the definition of a chest tube?
Placement of tubes and use of suction to return negative pressure to intrapleural space, expands lungs by removing positive pressure from pleural space
75
True or false
Milking and stripping chest tubes is contraindicated because it increases negative intrapleural pressure, it does not significantly affect tube patency
True
76
Should you turn the client frequently if they have a chest tube in?
Yes
77
When will fluid fluctuate in a waterseal chamber?
The level will rise on inhalation and fall on exhalation
If there are no fluctuations either the lung has expanded fully or the chest tube is clogged
78
Where does crepitus occur for a chest tube?
Crepitus Will occur around the chest tube insertion site in the subcutaneous tissue also called subcutaneous emphysema
79
True or false
| Chest tube clamps are used judiciously and only in emergency situations because they can cause tension pneumothorax
True
80
What should you do for a post op chest tube person?
Encourage movement, coughing, deep breathing every 2 hours, splinting, effective pain management improves performance
81
What is a sign of tension pneumothorax?
Assess for tracheal deviation
82
What should you instruct when withdrawing a tube ?
To exhale or bear down while holding breath as the tube is withdrawn (valsalva maneuver)
83
How often should you perform tracheostomy care?
Every eight hours
84
Why is a chest tube placed?
```
It is used to remove air (pneumothorax)
Or
Fluid (pleural effusion)
Or
Pus (empyema)
```
85
What size chest tubes are used for adults?
20-40 French
86
What is pneumothorax ?
Collapse of a lung resulting from disruption of negative pressure within the intrapleural space caused by presence of atmospheric air in the plural cavity
87
What are the types of pneumothorax or chest injuries?
1. Spontaneous or simple
2. Traumatic
3. Hemothorax
4. Tension
88
What is a spontaneous or simple pneumothorax?
It occurs when the weakened area of lung ruptures, air moves from lung to intrapleural space, causing collapse, highest incidence is in men 20 to 40 years of age
89
What is a traumatic pneumothorax?
Disruption of plural space by invasive chest procedures, lacerations through chest wall into intrapleural space, or penetration by fractured rib
90
What is the hemothorax?
Collection of blood within plural cavity often accompanies traumatic pneumothorax, blood disrupts negative pressure of plural space
91
What is a tension pneumothorax?
Build up of pressure as air accumulates within pleural space, pressure increases causing lung to collapse, pressure displaces trachea, esophagus, heart, and great vessels toward unaffected side. This causes increased thoracic pressure, reduce venous return, and decreased cardiac output.
92
A client was shot in the chest during a hold up and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expected to the second intercostal space to accomplish?
It will remove the air that is present in the intrapleural space
93
How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?
Subcutaneous emphysema occurs when air leaks from intrapleural space through the thoractomy or around the chest tubes into the soft tissue. So you should palpate around the tube insertion site for crepitus.
94
During the first 36 hours after the insertion of chest tubes, when assessing the function of the three chamber, closed chest drainage system, the nurse identifies that the water in the underwater Seal tube is not fluctuating. What initial action should the nurse take?
Check the tube to insure that is not kinked
95
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asked how could this happen? What likely cause of the spontaneous pneumothorax should the nurses response take into consideration?
Rupture of a subpleural bleb
-The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air
96
What clinical indicators should the nurse expect identify when assessing an individual with a spontaneous pneumothorax?
1. Shortness of breath
| 2. Unilateral chest pain
97
A client diagnosed with a spontaneous pneumothorax. Which psychological effect of a spontaneous pneumothorax should the nurse included teaching plan for the client?
Air will move from the lung into the plural space
-as a person with a tear in a long inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung
98
When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern?
Decrease filling out the right heart
-pressure within the plural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output
99
A chest tube is inserted into a client who was stabbed in the chest and is attached to a close drainage system. Which is an important nursing intervention when caring for this client?
Observed for fluid fluctuations in the waterseal chamber
-fluctuations occur when inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur the chest tube maybe clogged or kinked, coughing should be encouraged
100
The client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?
Palpate the surrounding area for crepitus
101
The nurses taking a report on a patient who had a pneumectomy four days ago. At which question is the best ass during the shift report?
Does the surgeon want the patient placed on the non-operative side?
102
The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient?
The patient is encouraged to cough and do deep breathing exercises frequently
103
Upon observation of a chest tube set up, the nurse reports to the physician that there is a leak in the chest tube and system. How has the nurse identify this problem?
There was an onset of vigorous bubbling in the waterseal chamber
105
Upper G.I. bleeding often requires a healthcare provider to insert a large bore nasogastric tube to do what?
1. Determine the presence or absence of blood in the stomach
2. Assess the rate of bleeding
3. Prevent gastric dilation
4. Administer Lavage
106
What does gastric Lavage require?
It requires insertion of a large bore NGT with installation of room temp solution in volumes of 200 to 300 mL. The solution and bladder repeatedly withdrawn manually until returns are clear or light pink and without clock. Instructed patient to lie on the left side during this procedure to limit the flow of the lavage solution out of the stomach.
107
A client is going to have a gastric Lavage. In which position should the nurse place the client when the nasogastric tube is being inserted.
High fowlers, it promotes optimal entry into the esophagus aided by gravity
108
Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the clients nasogastric tube is bright red. What should the nurse do first?
Determine that this is an expected finding, nasogastric drainage is expected to be bright red during the first 12 hours after surgery
109
Client has admitted to the surgical unit from the postanesthesia care unit with the Salem sump nasogastric tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client?
Use normal sailing to irrigate the tube
110
After partial gastrectomy is performed, a client is returned from the postanesthesia care unit to the surgical unit with an IV solution infusing a nasogastric tube in place. The nurse identifies that there is no nasogastric drainage for 30 minutes. There's an order for installation of the nasogastric tube PRN. The nurses and still what?
30 mils of normal saline and continuous suction, physiologic normal saline if used in gastric installations to prevent electrolyte imbalance. Because of the fresh gastric sutures, slow and gentle installation of saline should be performed to reestablish patency of the tube, and then the tube should be reconnected to suction to ensure stomach decompression
111
How should the nurse prepare an IV piggyback medication for administration took client receiving an IV infusion?
1. Wear clean gloves to check that IV site
2. Rotate the bag after adding the medication
6. Use a sterile technique when preparing the medication
112
The nurse administers an intravenous solution of 0.45% sodium chloride. And what category of fluids the solution belong?
Hypotonic
113
What clinical findings of the nurse anticipate when admitting a client with an extracellular fluid volume access?
Distended jugular veins
114
A nurses caring for a client with diarrhea. In which clinical indicator does the nurse anticipated decrease?
Tissue turgor
115
A client reports vomiting and diarrhea for three days. What clinical finding one most accurately indicate that the client has a fluid deficit?
Loss of bodyweight
116
The nurse is reviewing a client sir I'm electrolyte laboratory report. What is the comparison between blood plasma and interstitial fluid?
They both contain the same kind of ion
117
A nurse explained to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular by fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?
Interstitial fluid
118
A nurse assesses the clients serum electrolyte levels in the lab report. What electrolyte in the intracellular fluid should the nurse consider most important?
Potassium, The concentration of potassium is greater inside the cell is important in establishing the membrane potential, a critical factor in the cells ability to function
119
A nurse is reviewing the lab report of a client with a tentative diagnosis of kidney failure what mechanism does the nurse expect to be maintained when ammonias excreted by healthy kidneys?
Acid-base balance of the body
120
The nurses evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?
Clear breath sounds
121
The nurses caring for a client with albuminuria resulting in edema. What pressure changed as the nurse determined as the cause of the edema?
Decrease in plasma colloid oncotic pressure
122
A nurse is reviewing the healthcare providers orders for client was admitted with dehydration as a result of prolonged watery diarrhea. Which order should the nurse question?
Parenteral albumin (albuminar)
123
The nurses analyzing how I hyperglycemic clients blood glucose can be lowered. The nurse considers that the chemical that buffers the clients excessive acetoacetic acid is..
Bicarbonate
124
For what clinical indicator should a nurse assessed the client who is having a gastric lavage?
Increased serum bicarbonate level
125
The nurses concern the client is at risk for developing hyperkalemia. Which disease does the client have that has causes concern?
End-stage renal disease
126
A clients serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?
Take vital signs and notify the healthcare provider
127
What clinical indicators of the nurse expect a client with hyperkalemia to exhibit?
1. Diarrhea
2. Weakness
3. Dysrhythmias
128
I nurse adds 20 of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering the drug?
To replace excessive losses
129
A nurses caring for a client with ascites. What does the nurse considered to be the cause of this?
Diminished plasma protein level
130
A client is receiving an IV infusion of 5% dextrose and water. The client loses weight and develop the negative nitrogen balance. What nutritional problem prompts the nurse to notify the healthcare provider?
Lack of protein supplementation
131
A nurses caring for a client with ascites who is receiving albumen. What infusion rate and oral fluid intake to the nurse expect to have the greatest therapeutic effect?
Slow IV rate and restricted fluid intake
132
The nurse is preparing to start an infusion of a 10% dextrose. Why does the nurse infuse the solution through central line?
The osmolarity of the solution could cause phlebitis or thrombosis
133
The patient is in the hospital for his first chemotherapy treatment for lung cancer which IV access methods are appropriate for this patient?
1. Peripherally inserted central catheter
2. Tunneled central venous catheter
3. Implanted port
134
The patient has a peripherally inserted central catheter inserted and is in order to receive IV cisplatin. The drug has infiltrated into the tissue and redness is observed in the right lower side of the neck. What interventions, and order of priority, will the nurse perform?
1. Stop the infusion and disconnect the IV line from the administration set
2. Aspirate the drug from the IV access device
3. Apply cold compresses to the site of swelling
4. Monitor the patient and document
135
The nurse is preparing to give a patient IV drug therapy. What information does the nurse need before administering the drug?
1. Indications, contraindications, and precautions For IV therapy
2. Appropriate dilution, pH, and osmolarity of solution
3. Rate of infusion and dosage of drugs
4. Compatibility with other IV medications
5. Specifics of monitoring because of immediate effect
136
The charge nurse is reviewing IV therapy orders. What information is included in each order?
1. Specific type of solution
2. Rate of administration
3. Specific drug dose to be added to the solution
137
The nurse must insert a short peripheral IV catheter. In order to decrease the risk of devein thrombosis or phlebitis, which Faindis the nurse choose for the infusion site?
Forearm
138
The physicians prescriptions indicate an increase in the suction to -20 cm for patient with a chest tube. To implement this, the nurse performed which intervention?
Stops the suction, add sterile water to level of -20 cm to the water seal chamber, and resumes the wall suction
139
When inflating the cuff of a tracheostomy tube's outer cannula, between ___________ ml of air should be used.
10 and 20 ml
140
When checking cuff pressure using a manometer, the reading should be between:
14 and 20 mm hg
141
Tracheoesophageal fistula
Food particles appearing in secretions
142
Tracheomalacia
An increasing amount of pressure is needed to maintain a seal between the trachea and the tube
143
Tracheal stenosis
Stricture of the trachea
144
Tracheomalacia
Softening of the connective tissue of the trachea
145
Tracheal stenosis
Frequent coughing, difficulty breathing or expectorating secretions after the tracheostomy tube has been removed
146
Tracheal-innominate artery fistula
Trach tube pulsating with the patient's heartbeat
147
To reduce risk of tube obstruction secondary to secretions:
a) encourage the patient to cough and deep breathe.
b) provide humidification when administering room air to oxygen.
c) ensure the patient is well-hydrated.
148
If decannulation occurs within the first 72 hours post-tracheostomy, emergency interventions include:
inserting a suction catheter through the stoma.
149
The following equipment should always be kept at the bedside of a patient with a tracheostomy:
b) ambu bag with the correct adaptor for the trach tube.
| c) suction catheters.
150
Tracheostomy patients lose their ability to speak because:
air which normally flows through the vocal cords is diverted.
151
Weaning from a tracheostomy tube includes:
deflating the cuff and using a fenestrated tube
152
The outer cannula of the trach tube should be changed:
Per manufacturer's recommendations or doctor's orders.
153
The size of suctioning catheter in tracheostomy should be
The catheter's external diameter should be less than half the internal diameter of the tracheostomy tube
154
Pneumothorax is most commonly seen with...
Low tracheostomy
155
Tracheal stenosis is more common with ....
High tracheostomy
156
A nurse is inserting a nasogastric
tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action?
During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides.
157
Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would:
Clamp the nasogastric tube for 30 minutes following administration of the medication,
If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration.
158
Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take?
Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Th
159
A nurse checking an IV fluid order questions its accuracy. What does the nurse do first?
Contacts the health care provider who ordered it
160
A client is to receive an IV solution of 5% dextrose and half-normal saline at 125 mL/hr. Which system provides the safest method for the nurse to accurately administer this solution?
Infusion pump
161
A client who used to work as a nurse asks, "Why is the hospital using a 'fancy new IV' without a needle? That seems expensive." How does the nurse respond?
"They minimize health care workers' exposures to contaminated needles."
162
A nurse is teaching a hospitalized client who is being discharged about how to care for a peripherally inserted central catheter (PICC) line. Which client statement indicates a need for further education?
"I can continue my 20-mile running schedule as I have for the past 10 years."
163
A nurse is admitting clients to the same-day surgery unit. Which insertion site for routine peripheral venous catheters does the nurse choose most often?
Cephalic vein of the forearm
164
A client admitted to the intensive care unit (ICU) is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device does the nurse choose for this client?
Midline catheter
165
A 22-year-old client is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this client's intravenous (IV) solution?
An 18-gauge catheter is the size of choice for clients who will undergo surgery. If they need to receive fluids rapidly, or if they need to receive more viscous fluids (such as blood or blood products), a lumen of this size would accommodate those needs.
166
A client who is receiving intravenous antibiotic treatments every 6 hours has an intermittent IV set that was opened and begun 20 hours ago. What action does the nurse take?
Changes the set in about 4 hours
167
A client is seen in the emergency department (ED) with pain, redness, and warmth of the right lower arm. The client was in the ED last week after an accident at work. On the day of the injury, the client was in the ED for 12 hours receiving IV fluids. On close examination, the nurse notes the presence of a palpable cord 1 inch in length and streak formation. How does the nurse classify this client's phlebitis?
Grade 3
168
A nurse who is starting the shift finds a client with an IV that is leaking all over the bed linens. What does the nurse do initially?
Assesses the insertion site
169
A client is admitted to the cardiothoracic surgical intensive care unit (ICU) after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. What assessment does the nurse make to ensure patency of the client's arterial line?
Capillary refill and pulse
170
A client is being admitted to the burn unit from another hospital. The client has an intraosseous IV that was started 2 days ago, according to the client's medical record. What does the admitting nurse do first?
Anticipates an order to discontinue the intraosseous IV and start an epidural IV
171
A nurse is to administer a unit of whole blood to a postoperative client. What does the nurse do to ensure the safety of the blood transfusion?
To ensure safety, blood must be checked by two qualified health care professionals, usually two registered nurses. Administering an incorrectly matched unit of blood creates great consequences for the client and is considered to be a sentinel event.
172
A nurse is starting a peripheral IV catheter on a recently admitted client. What actions does the nurse perform before insertion of the line?
Povidone-iodine (Betadine) is applied to the selected insertion site before insertion. The solution is allowed to dry, which takes about 2 minutes.
Correct: The insertion site should be cleansed before the antiseptic skin preparations are completed.
Correct: After soap and water cleaning, prepping with 70% alcohol or chlorhexidine is done.
173
A nurse is administering a drug to a client through an implanted port. Before giving the medication, what does the nurse do to ensure safety?
Checks for blood return
174
Which client does the charge nurse on a medical-surgical unit assign to the LPN/LVN?
Older client admitted for confusion who has a heparin lock that needs to be flushed every 8 hours
175
A client who takes corticosteroids daily for rheumatoid arthritis requires insertion of an IV catheter to receive IV antibiotics for 5 days. Which type of IV catheter does a nurse teach the new graduate nurse to use for this client?
Midline catheter
176
A nurse assessing a client's peripheral IV site obtains and documents information about it. Which assessment data indicate the need for immediate nursing intervention?
The vein feels hard and cordlike above the insertion site.
177
When flushing a client's central line with normal saline, a nurse feels resistance. Which action does the nurse take first?
Stops flushing and tries to aspirate blood from the line
178
A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV line placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?
RN with certified registered nurse infusion (CRNI) certification who is assigned to the emergency department for the day`
179
A nurse is inserting a peripheral intravenous (IV) catheter. Which client statement is of greatest concern during this procedure?
My hand tingles when you poke me."
180
A 70-year-old with severe dehydration is ordered an infusion of an isotonic solution at 250 mL/hr through a midline IV catheter. After 2 hours, the nurse notes that the client has crackles throughout all lung fields. Which action does the nurse take first?
Slows the rate of the IV infusion
181
A nurse is revising an agency's recommended central line catheter-related bloodstream infection prevention (CR-BSI) bundle. Which actions decrease the client's risk for this complication?
Thorough hand hygiene (i.e., no quick scrub) before insertion
Using chlorhexidine for skin disinfection
Immediately removing the client's venous access device (VAD) when it is no longer needed
182
A client has a tracheostomy with a nondisposable inner cannula. After completing tracheostomy care, the nurse reinserts the inner cannula into the tracheostomy tube immediately after doing which of the following?
1. Suctioning the airway
2. Rinsing it in sterile water
3. Drying it with a sterile cotton ball
4. Tapping it dry lightly against a sterile surface
Tapping it dry lightly against a sterile surface
Rationale: The nurse reinserts the inner cannula immediately after tapping it dry against a sterile surface. Once inserted, it is turned clockwise to lock it into place. It should not be dried with a cotton ball, which could leave cotton particles on the cannula. The client's airway is suctioned before doing tracheostomy care. It is rinsed in sterile water before it is tapped.`
183
A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client?
1. Measuring the pH of gastric aspirate
2. Submerging the NG tube in water to check for bubbling
3. Aspirating the NG tube with a 50 mL syringe for gastric contents
4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach
. Submerging the NG tube in water to check for bubbling
Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.
184
A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first?
1. Aspirate the tube
2. Flush the tube with warm water
3. Prepare to remove and replace the tube
4. Flush with a carbonated liquid such as cola
Aspirate the tube
Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful.
185
nurse is preparing to suction a client's tracheostomy. To ideally promote deep breathing and coughing, in which position should the client be safely placed?
1. Supine
2. Lateral position
3. High-Fowler's position
4. Semi-Fowler's position
Semi-Fowler's position
Rationale: If it is not contraindicated, before suctioning a tracheostomy, the client is placed in semi-Fowler's position to promote deep breathing, maximum lung expansion, and productive coughing. With the client in this position, gravity pulls downward on the diaghram, which allows greater chest expansion and lung volume. Options 1 and 2 would not provide maximum lung expansion. The high-Fowler's position would not allow for easy visualization of the tracheostomy or easy access of the suction catheter.``
186
Hypertonic
Concentration of salt is greater in the ECF compartment which causes the cell to SHRINK!!
Takes water from within the cell and moves it into ECF compartment, causing cell to shrink.
PERFECT FOR EDEMA!! CAN CAUSE DEHYDRATION!
(thicker than blood, pulls water into blood)
187
Hypotonic
Contains less salt than the intracellular space.
Causes water to MOVE INTO THE CELL, which swells the cell
CAN CAUSE CELLS TO BURST!!!!!! MUST BE VERY CAREFUL!
USED FOR DEHYDRATION!! watch for fluid overlaod(swelling, frothy pink saliva)`
188
Isotonic solutions
0.9% normal saline (NS)
Dextrose 5% in water or NS
Lactated Ringers
189
Hypertonic solutions
5% dextrose in water
0.9% NS (D5 NS)
Used to replace electrolytes and to shift ECF from interstitial tissue to plasma (gonna make pt thirty
190
Hypotonic solutions
2.5% Dextrose in water
0.45% Saline (or half NS)
These fluids hydrate cells, but can deplete the blood)
191
A patient is hypovolemic and plasma volume expanders are not availaible. What kind of solutions do you administer?
Hypertonic solutions pull O2 from intracellular and interstitial into vascular thus they expand the plasma space.
192
A disadvantage of Telfon over-the-needle catheter for peripheral is
increases the risk of mechanical phlebitis.
193
Which of the following connections should be used to secure a piggyback administration set to the primary administration set?
The male Luer lock has threads that secure and lock the connectors.
194
Midclavicular placement of a central line catheters are inserted into a
superficial vein of the peripheral vascular systems and advanced to the proximal axillary or subclavian veins. Radiographic confirmation is optional.
195
According to the Infusion Nurse Society’s Standards of Practice, a`
0.22um filter may be used for the delivery of infusion therapy to decrease the risk of air emboli.
196
Hypotonic solutions are used to:
hydrate cells.`1
197
The standard blood administration set has a clot filter of :
170 um.
198
Which of the following solutions are considered colloid solutions?
Albumin is a natural plasma protein prepared from donor plasma.
199
The first symptom of venous spasm is:
A sharp pain extending from the site of infusion.
200
The physician is usually notified when there is a
3+ phlebitis.
201
On inspection on an IV site, the nurse discovers a 2+ phlebitis. The appropriate nursing intervention would be to:
Treatment for suspected phlebitis is first to remove the cannula and then to restart a cannula in a new IV site if appropriate. Apply hot or cold compress to the affected side.
202
How/where do you apply Kelly clamps when changing the drainage system? (in red) The Kelly clamps prevent what?
Apply Kelly clamps 1.5 - 2.5 inches from insertion site and 1 inch apart, going in opposite directions. Kelly clamps prevent air from entering the pleural space through the chest tube`
203
You must keep the end of the chest tube _________ upon insertion of the end of the new drainage system into the chest tube.
STERILE
204
The physician WILL order what after the chest tube removal?
Chest X-Ray
205
How often do you change the dressings for chest tubes
q. 24 hours
206
A "closed water seal" drainage system prevents what?
| The "suction control chamber" prevents what?
1. Air from entering the chest once it has escaped
| 2. suction pressure from being applies to the pleural cavity
207
The drainage amount recorded should be a __________ ________ since the drainage system is __________ _________ because if you open the system it will lose its _____________ pressure.
1. running total
2. never emptied
3. negative
208
If the patient has a small pneumothorax what may be used?
Hemilich valve`
209
Placing the tube beyond the _______ decreases the risk of aspiration:
pylorus
210
Infants would use which size NG tube?
8 fr
211
Adults would use which size NG tube?
12 FR
212
How often do NG tube placements need to be verified?
q 4 - 6 hours
