Exam 1 Flashcards
In what type of injection should the Z-track method be utilized?
intramuscular
What is the rationale for usage of the Z-track method in intramuscular injections?
the zigzag path seals the needle track, preventing the contents of the injection escaping the muscle tissue
What layers of tissue should be displaced during intramuscular injection administration (Z-track)?
skin and subcutaneous tissue
If the nurse experiences a problem reading a provider’s medication order, what would be an appropriate action for the nurse to take?
call the provider to verify order
What are the rights of medication administration?
-right medication
-right dose
-right client
-right route
-right time
-right documentation
Should the nurse document medication before or after giving it to a client?
after
What is the most desired route of administration? What is the rationale?
oral, as it is the least invasive
What is an important safety consideration for the nurse while administering topical medication?
using gloves to prevent absorption into nurse’s skin
What should be considered when applying a topical patch to a patient?
rotation of sites as well as removing previous patches to prevent over medicating
Nasal drops are to sterile as nasal spray is to ______.
clean
What should be done to nasal spray after each use?
tip should be cleaned
If a patient must receive more than 1 type of eye drop, how much time must elapse before the second type of medicated drop can be used?
5 mins to allow for absorption of first drops
What would be a contraindication for using ear drops?
ruptured or perforated tympanic membrane
How must medication utilized in rectal instillation be stored?
refrigeration or suppository will melt
What device can be used for individuals experiencing difficulty coordinating actions while using a inhaler?
spacer
For open wounds, what type of irrigation solution must be used?
sterile water
For medication stored in a glass ampule, what measure must be taken to ensure safety?
aspirate medication into syringe using a filter straw/needle to avoid glass in injection
Where are common sites for subcutaneous injections?
belly and back of arms
What type of injection can be given with a 45-90 degree angle depending on patient adipose?
subcutaneous
What angle should a intramuscular injection be given?
90 degrees
What angle would be effective for an intradermal injection?
15 degrees
What would indicate a successful administration of an intradermal injection?
presence of bleb or wheal
Name 3 sites utilized for intramuscular medication injections:
deltoid, ventrogluteal and vastus lateralis
What type of tubing is often used for decompression (removal of gastric contents)?
NG (nasogastric) tube
What type of enteral tube is placed directly into the stomach?
Percutaneous endoscopic gastrostomy tube (PEG)
What type of enteral tube is placed directly into the small intestine?
Percutaneous endoscopic jejunostomy tube (PEJ)
What is a benefit of feeding via PEJ tubes?
nutrition is given past pyloric sphincter, reducing risk for aspiration, given the feeding doesn’t reflux into stomach
What must be used to flush enteral feeding tubes for immunocompromised or critically ill patients?
sterile water
How must meds be given through an enteral tube?
SEPERATELY, and then followed by 15-30 ML of water between
What action must be taken prior to giving medication through an enteral tube?
flush the tube with 15 mL of water with a 60 mL syringe
What are of special importance in clients with impaired cognition to decrease the risk for aspiration during gastric feeding?
gastric residual checks
How can a nurse minimize gastric cramping in intermittent or bolus feeding?
ensure formula is at room temperature
How long should a client remain sitting up after bolus feeding?
1 hr
What type of order refers to that which is given until prescriber changes it?
standing
What type of order is given for a specific reason at a specific time?
single/ one-time
What type of order is for a single time and must be given within 90 mins?
Now order
What type of order is given when patient requires it?
PRN
What type of order must be acted upon immediately?
STAT
What type of order is for medication given outside of hospital?
prescriptions
What is the anatomical landmark for intramuscular injections given in the deltoid?
acromion process
With which type of medication administration must another personnel be present as a witness due to its vulnerable nature?
vaginal instillation
What is priority in MRI safety?
patient must remove all metal
Which urine specimen collection evaluates C and S?
What is C & S?
clean catch/ “mid-stream”
culture (what is it?) and sensitivity (how can it be killed?)
What are some priorities of client education for a clean catch/”mid stream” urine specimen collection?
use palm to hold lid; don’t touch inside. do not allow to container to touch the perineal area/skin.
When is a first morning/ 8-hour urine specimen likely used?
pregnancy test hCG
What action must a nurse take with urine specimens before taking them to the lab?
place the samples in a biohazard bag
What is the greatest risk for CAUTI?
prolonged used of the urinary catheter, so they should be removed as soon as possible
What may be an appropriate action for acute urinary retention caused by nerve injury?
utilization of catheter
What must a client do before a 24 hour urine start time can begin?
void/empty bladder
What range is a reliable indicator of stomach placement enteral feedings?
pH of 0-4
How far should a catheter be inserted for females?
1-2 inches more than when urine is obtained
How far should a catheter be inserted in males?
to the Y bifurcation of the catheter
What should be used to inflate the balloon once the catheter is in place?
Sterile water
What should a catheter drainage bag NOT be placed on?
Movable part of the bed
How should a 24 hr urine specimen container be stored?
continually on ice
What is the purpose of a capillary blood glucose?
To determine or monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia
What is the purpose of a 24 hr urine specimen collection?
measure the components of urine and is used to assess renal function
What type of insulins should not be mixed with other types of insulins?
(Lantus) or insulin detemir (Levemir)
What is NPH?
neutral protamine
Hagedorn
Why is it important to check for gastric residual volume before feedings in intermittent feedings?
because volume greater than 10 mL may indicate displacement of tubing
What are some indications for feeding tube placement?
anorexia nervosa, CVA
True or False: Patient must discontinue all meds during a 24hr urine specimen collection.
False
