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PCC2: Parker > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

In what type of injection should the Z-track method be utilized?

A

intramuscular

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2
Q

What is the rationale for usage of the Z-track method in intramuscular injections?

A

the zigzag path seals the needle track, preventing the contents of the injection escaping the muscle tissue

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3
Q

What layers of tissue should be displaced during intramuscular injection administration (Z-track)?

A

skin and subcutaneous tissue

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4
Q

If the nurse experiences a problem reading a provider’s medication order, what would be an appropriate action for the nurse to take?

A

call the provider to verify order

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5
Q

What are the rights of medication administration?

A

-right medication
-right dose
-right client
-right route
-right time
-right documentation

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6
Q

Should the nurse document medication before or after giving it to a client?

A

after

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7
Q

What is the most desired route of administration? What is the rationale?

A

oral, as it is the least invasive

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8
Q

What is an important safety consideration for the nurse while administering topical medication?

A

using gloves to prevent absorption into nurse’s skin

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9
Q

What should be considered when applying a topical patch to a patient?

A

rotation of sites as well as removing previous patches to prevent over medicating

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10
Q

Nasal drops are to sterile as nasal spray is to ______.

A

clean

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11
Q

What should be done to nasal spray after each use?

A

tip should be cleaned

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12
Q

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?

A

5 mins to allow for absorption of first drops

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13
Q

What would be a contraindication for using ear drops?

A

ruptured or perforated tympanic membrane

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14
Q

How must medication utilized in rectal instillation be stored?

A

refrigeration or suppository will melt

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15
Q

What device can be used for individuals experiencing difficulty coordinating actions while using a inhaler?

A

spacer

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16
Q

For open wounds, what type of irrigation solution must be used?

A

sterile water

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17
Q

For medication stored in a glass ampule, what measure must be taken to ensure safety?

A

aspirate medication into syringe using a filter straw/needle to avoid glass in injection

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18
Q

Where are common sites for subcutaneous injections?

A

belly and back of arms

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19
Q

What type of injection can be given with a 45-90 degree angle depending on patient adipose?

A

subcutaneous

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20
Q

What angle should a intramuscular injection be given?

A

90 degrees

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21
Q

What angle would be effective for an intradermal injection?

A

15 degrees

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22
Q

What would indicate a successful administration of an intradermal injection?

A

presence of bleb or wheal

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23
Q

Name 3 sites utilized for intramuscular medication injections:

A

deltoid, ventrogluteal and vastus lateralis

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24
Q

What type of tubing is often used for decompression (removal of gastric contents)?

A

NG (nasogastric) tube

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25
Q

What type of enteral tube is placed directly into the stomach?

A

Percutaneous endoscopic gastrostomy tube (PEG)

26
Q

What type of enteral tube is placed directly into the small intestine?

A

Percutaneous endoscopic jejunostomy tube (PEJ)

27
Q

What is a benefit of feeding via PEJ tubes?

A

nutrition is given past pyloric sphincter, reducing risk for aspiration, given the feeding doesn’t reflux into stomach

28
Q

What must be used to flush enteral feeding tubes for immunocompromised or critically ill patients?

A

sterile water

29
Q

How must meds be given through an enteral tube?

A

SEPERATELY, and then followed by 15-30 ML of water between

30
Q

What action must be taken prior to giving medication through an enteral tube?

A

flush the tube with 15 mL of water with a 60 mL syringe

31
Q

What are of special importance in clients with impaired cognition to decrease the risk for aspiration during gastric feeding?

A

gastric residual checks

32
Q

How can a nurse minimize gastric cramping in intermittent or bolus feeding?

A

ensure formula is at room temperature

33
Q

How long should a client remain sitting up after bolus feeding?

A

1 hr

34
Q

What type of order refers to that which is given until prescriber changes it?

A

standing

35
Q

What type of order is given for a specific reason at a specific time?

A

single/ one-time

36
Q

What type of order is for a single time and must be given within 90 mins?

A

Now order

37
Q

What type of order is given when patient requires it?

A

PRN

38
Q

What type of order must be acted upon immediately?

A

STAT

39
Q

What type of order is for medication given outside of hospital?

A

prescriptions

40
Q

What is the anatomical landmark for intramuscular injections given in the deltoid?

A

acromion process

40
Q

With which type of medication administration must another personnel be present as a witness due to its vulnerable nature?

A

vaginal instillation

41
Q

What is priority in MRI safety?

A

patient must remove all metal

42
Q

Which urine specimen collection evaluates C and S?
What is C & S?

A

clean catch/ “mid-stream”

culture (what is it?) and sensitivity (how can it be killed?)

43
Q

What are some priorities of client education for a clean catch/”mid stream” urine specimen collection?

A

use palm to hold lid; don’t touch inside. do not allow to container to touch the perineal area/skin.

44
Q

When is a first morning/ 8-hour urine specimen likely used?

A

pregnancy test hCG

45
Q

What action must a nurse take with urine specimens before taking them to the lab?

A

place the samples in a biohazard bag

46
Q

What is the greatest risk for CAUTI?

A

prolonged used of the urinary catheter, so they should be removed as soon as possible

47
Q

What may be an appropriate action for acute urinary retention caused by nerve injury?

A

utilization of catheter

48
Q

What must a client do before a 24 hour urine start time can begin?

A

void/empty bladder

49
Q

What range is a reliable indicator of stomach placement enteral feedings?

A

pH of 0-4

50
Q

How far should a catheter be inserted for females?

A

1-2 inches more than when urine is obtained

51
Q

How far should a catheter be inserted in males?

A

to the Y bifurcation of the catheter

52
Q

What should be used to inflate the balloon once the catheter is in place?

A

Sterile water

53
Q

What should a catheter drainage bag NOT be placed on?

A

Movable part of the bed

54
Q

How should a 24 hr urine specimen container be stored?

A

continually on ice

55
Q

What is the purpose of a capillary blood glucose?

A

To determine or monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia

56
Q

What is the purpose of a 24 hr urine specimen collection?

A

measure the components of urine and is used to assess renal function

57
Q

What type of insulins should not be mixed with other types of insulins?

A

(Lantus) or insulin detemir (Levemir)

58
Q

What is NPH?

A

neutral protamine
Hagedorn

59
Q

Why is it important to check for gastric residual volume before feedings in intermittent feedings?

A

because volume greater than 10 mL may indicate displacement of tubing

60
Q

What are some indications for feeding tube placement?

A

anorexia nervosa, CVA

61
Q

True or False: Patient must discontinue all meds during a 24hr urine specimen collection.

A

False

PCC2: Parker (6 decks)

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