Exam 3

Question 1

Layers of skin + physiology:

Answer 1

Largest Organ: 15% of total body weight

Provides….
Protective barrier against disease- causing temperature
Sensory organ for pain, temperature, touch
Vitamin D synthesis(immune system, mood)

Impaired skin integrity from wound, surgery, pressure injury; injury to skin poses risk to safety and triggers complex healing response

Question 2

Factors Affecting the skin including developing considerations:

Answer 2

Unbroken and healthy skin and mucous membranes are first line of defense against harmful agents

resistance to injury is affected by age, amount of underlying tissue, and illness

adequately nourished, and hydrated body cells are resistant to injury

adequate circulation is necessary to maintain cell life

Developmental Considerations…
in children younger than 2 years, skin is thinner and weaker than adults

infants skin + mucous membrane are easily injured and subject to infection; child skin becomes increasingly resistant to injury and infection

structure of skin changes as person ages; maturation of epidermal cells is prolonged; leading to thin, easily damaged skin

circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure

Question 3

Causes of Skin alterations:

Answer 3

Very thin and very obese people are more susceptible to skin injury
—–> fluid loss during illness causes dehydration
—–> skin appears loose and flabby

excessive perspiration during illness predisposes skin to breakdown

Question 4

Types of Wounds:

Answer 4

Intentional vs unintentional (intentional; surgery, unintentional: cuts)

Closed or open:
( open: abrasions, closed: fall-strain, soft tissue damage)

Acute vs chronic:
(chronic is linked to decreased circulation; venous stasis, arterial ulcers, pressure injury, diabetic foot ulcers, neuropathy; Acute: surgical, trauma)

Partial thickness, full thickness, complex (complex, greater than 3 months)

Question 5

Principles of Wound Healing:

Answer 5

Intact skin is first line of defense against microorganism

Careful hand hygiene is used in caring for wound

body responds systematically to trauma of any of its parts

adequate blood supply is essential for normal body response to injury

normal healing is promoted when wound is free of foreign material

extent of damage and persons state of health affect wound healing

response to wound is more effective if proper nutrition is maintained

Question 6

Phases of wound healing:

Answer 6

Hemostasis: vasoconstriction, coagulation, platelet aggregation, beginning of growth factor secretion, exudate is formed- causing swelling and pain, increased perfusion results in heat and redness

inflammatory: vasodilation, WBC (leukocytes and macrophages move to the wound)

Proliferation: Re-epitheliamization, angiogenesis, collagen synthesis, granulation tissue forms a foundation for scar tissue development

Maturation: collagen remodeling, scar tissue becomes a flat, thin, white line

Question 7

Process of Wound healing:

Answer 7

Primary Intention:
edges are approximated
surgical incisions heal by primary intention
risk of infection low

Secondary Intention:
burn, pressure injury, severe laceration
filled with scar tissue
longer to heal
risk of infection higher
loss of tissue function is permanent

Question 8

Systematic Factors affecting wound healing:

Answer 8

Age: children and healthy adults heal more rapidly

circulation and oxygenation: adequate blood flow is essential

Nutritional Status: healing requires adequate healing
–> need 1500 kcal/day for skin and wound healing
—> vitamin A, C , calories and protein to heal
—> malnourished patient

Wound etiology: specific conditions of wound affect healing

Infection:
prolongs inflammatory phase, delays collagen synthesis, and prevents epithealization and tissue destruction

Health status: corticosteriod drugs, and postoperative radiation therapy delay healing

Immunosuppresion

Medication use: anti-inflammatory and antineoplastic

adherence to treatment plan

Question 9

Complications of wound healing:

Answer 9

Hemorrhage (internally or externally)
—>Hematoma (swelling, change in color, sensation, warmth, blueish color)
—>assess post op and greatest risk 24-48 hrs, after surgery/injury

Infection:
- erythema, increased amount of wound drainage, change in appearance of wound drainage (thick, color change, odor) peri wound warmth, pain, edema, fever, tenderness, elevated WBC, wound edges inflamed, drainage is present: odor, purulent: yellow, green, brown color)

Dishiscence:
-partial or total separation of wound layers

Evisceration:
protrusion of visceral organs through wound opening
- emergency: damp sterile guaze over site: call for help

Fistula:
- tunneling: channel that extends in any direction from wound through subcutaneous tissue
- undermining: tissue destruction underlying intact skin along wound margins

Question 10

Pressure injuries: Risk Factors

Answer 10

Age

Impaired sensory perception

chronic illness

diabetics (decreased perfusion and impaired sensory perception)

immobility

spinal cord and brain injury

neuromuscular disorders

alterations in LOC

friction

shears

moisture (stool or urine)

low blood pressure

Malnutrition

Question 11

Pressure Injury: Classification

Answer 11

Stage 1: intact skin with no blanchable redness

Stage 2: partial thickness skin loss with exposed dermis

stage 3: full thickness skin loss with visible fat

stage 4: full-thickness skin with exposed bone, tendon, muscles

unstageable: obscured full-thickness skin and tissue loss by slough, and/or eschar, depth unknown

Deep tissue Pressure injury: persistent non- blanchable deep red, maroon, or purple discolorations ( do not massage over non- blanchable reddened areas) difficult to detect in individuals with dark skin tones

Question 12

Pressure Injury: Risk assessment:

Answer 12

Braden Scale
- risk assessment (the lower score indicated a higher risk of pressure ulcer development)

Sensory perception
moisture (incontinence or diaphoresis)
Activity (mobility, pain control helps promote mobility)
nutrition (malnutrition is a risk factor)
friction/shears

Question 13

Prevention of Pressure injury:

Answer 13

Risk Assessment: Braden Scale

Adequate nutrition: calories, protein, supplements

skin care:
- assess
- topical skin care and incontinence management

Positioning and mobilization:
- turn and reposition every 1-2 hrs
- positioning devices over bony prominence
- pressure relieving devices
—-> mattresses, overlay
——> seat cushion
—–> heel protecting device

elevating head 30 degrees or less decrease chance of pressure ulcer
elevated heels
transfer device to lift, then drag patient

Question 14

Pressure injury: Causes

Answer 14

external pressure compressing blood vessels, usually over a bony prominence

Friction or shearing forces tearing or injuring blood vessel

Question 15

Pressure Injury: assessment

Answer 15

be ready to write + Measure…
assess patient skin
assess level of sensation, movement, continence status
- continually assess skin for signs of breakdown, and/or ulcer development
-visual and tactile inspection of skin
- check over bony prominences, medical devices

Question 16

Wound Assessment

Answer 16

Wound Location: heal, ankle, sacrum

Wound Age: acute or chronic

Wound Depth:
Partial thickness wounds (epidermis and superficial dermal layers) shallow in depth, moist and painful, and the wound base generally appears red, heals by regeneration

Full- thickness wounds extend into the subcutaneous layer, and the depth and tissue type will vary depending on body location (may expose muscle or bone) heals by forming new tissues, takes longer to heal

Wound Color:
Red = healing
yellow(slough) = caution
black (eschar)= tissue death

Presence of undermining, tunneling, sinus tract

Wound Size:
- length x width x depth (cm)

Question 17

Wound Culture:

Answer 17

collect specimen from clean areas of granulation tissue of the wound

gram stains

tissue biopsy (gold standard)

Question 18

Cleaning a pressure injury/wound:

Answer 18

clean with each dressing change

know if the dressing change is clean or sterile: follow providers orders

use new guaze for each wipe and clean from top- bottom and/or center -outside

use .9% normal saline solution to irrigate and clean the injury

once the wound is cleaned, dry the area using gauze sponge in same manner

report any drainage or necrotic tissue

Question 18

First Aid for wounds:

Answer 18

Hemostasis:
control bleeding
– direct pressure
– do not remove penetrating object (object provides pressure and controls bleeding)
Bandage

Cleaning:
gentle cleaning
normal saline is preferred cleaning agent

protection:
light dressing applied over minor wounds prevents entry of microorganisms

Question 19

Packing A wound:

Answer 19

Assess size, depth, and shape of wound (measure & doc)

Packing needs to be in contact with entire wound, do not overpack

negative pressure wound therapy:
removes fluid, decreases edema, decrease number of bacteria and improves circulation to area

Question 20

Comfort Measure with wound care:

Answer 20

Administer analgesic medications 30-60 minutes before dressing changes

carefully remove tape

gently clean wound edges

carefully manipulate dressing and drains to minimize stress on senstitive tissue

turn and position patient carefully

Question 21

Safety Guidelines: Wound Care

Answer 21

Do NOT use wet to dry dressing (changed w/E-B)

Do NOT pull dressing off a wound; it can cause further damage (moisten dressing with little sterile water)

position patient to prevent the patient from rolling over the side of bed

keep a plastic bag within reach to discard dressing and prevent cross-contamination. keep extra gloves within reach to allow a change of gloves if the gloves become soiled

if irritating a wound, use appropriate PPE

when applying an elastic bandage, check for extremity for temperature, sensation changes

never massage reddened area

Question 22

Wounds: changing of dressing

Answer 22

know type of dressing, placement of drain, and equipment needed

prepare the patient for dressing change

review previous wound assessment

evaluate pain and if indicated, administer analgesics so peak effects during dressing change

describe procedure steps to lessen patient anxiety

gather all supplies

recognize normal signs of healing

answer questions about procedure or wound

Question 23

Wounds: purpose of dressing

Answer 23

protects from microorgamisms

aids in hemostasis

promotes healing by absorbing drain and debriding a wound

supports wound size

promotes thermal insulation

provides the right amount of moist environment

Question 24

Factors influencing heat and cold intolerance:

Answer 24

Method and duration of application

exposed skin: neck, inner aspect of wrist and forearm and perineal region are more sensitive, foot and palm of the hand are less sensitive

Amount of body surface covered by application

Temperature: body responds best to minor temperature adjustments, or larger areas of exposure

Age: very young and old most sensitve

perception of stimuli: reduced sensory perception, risk for injury is high

Question 25

Effects + devices of Cold:

Answer 25

Effects:
constricts peripheral blood vessels
reduces swelling and pain
reduces muscle spasms
prolonged exposure results in vasodilation

Devices to apply cold:
ice bags
cold packs
hypothermia blankets
cold compresses to apply moist cold

Question 26

Effects + devices of Heat:

Answer 26

Effects:
dilates peripheral blood vessels and improves blood flow to area
increase tissue metabolism
reduces blood viscosity and increases capillary permeability
reduces muscle tension and stiffness
helps relieve pain
prolonged exposure results in vasoconstriction and can lead to burns

Devices:
hot water bags
electic heating pads
aqua-thermia pads
hot packs
warm, moist compress
sitz bath
warm soaks

Question 27

Duration of Pain:

Answer 27

Acute:
less than 3 months
rapid onset, varies in intensity and duration
protective in nature

Chronic:
more than 3 months
may be limited, intermittent, or persistent
last beyond the normal healing period
idiopathic pain: no known cause
periods of remission or exacerbation are common

Question 28

The Pain Process:

Answer 28

Transduction: activation of pain receptors

Transmission: conduction along pathways (A-delta and C-delta fibers)

Perception of Pain: awareness of the characteristics of pain

• pain threshold: point at which a person feels pain
• pain tolerance: amount of pain a person is willing to bear

Modulation: inhibitation or modification of pain

Question 29

Gate Control Theory of Pain:

Answer 29

describes the transmission of painful stimuli and recognizes a relationship between pain and emotions

small- and large diameters nerve fibers conduct and inhibit pain stimuli toward the brain

Gating mechanism determines the impulses that reach the brain

Question 30

Origins of Pain:

Answer 30

Cutaneous:
In the skin or subcutaneous
Ex: superficial cut, bee sting

Somatic:
deep and diffuse (sharp, stabbing pain, localized)
ligaments, tendons, blood vessels, and bones
Ex: arthritis, bone fracture, or cancer

Visceral:
deep internal pain receptors
dull, heavy, aching pain occur over wide area, can cause referred pain
Ex: labor, pancreatitis, cancer

Radiating:
arises in one site and extends to another (sciatic pain)

Referred:
arises in one site but is felt in a distant site (MI, appendicitis)

Phantom: percieved as arising from a site that was surgically removed (amputation)

Physical:
cause of pain can be identified
cancer vs. Non- cancer pain

Psychogenic:
cause of pain cannot be identified
outdated term

Question 31

Common Responses to Pain:

Answer 31

Physiologic:
sympathetic response (moderate and superficial) or parasympathetic responses (severe and deep)

behavioral: grimacing, moaning, crying, restless, guarding

Affective:
stoicism, restlessness, anxiety, weeping, depression, fear, anger, anorexia, fatigue, hopelessness, powerlessness

Question 32

Factors affecting Pain experience:

Answer 32

Culture

ethnic variable

family, sex, gender, and age variables

religious beliefs

environment and support people

anxiety, fatigue, and other stressors

past pain experience and coping styles

Patient- centered care is required!!!!

be aware of bias!!!

Question 33

Assessment Parameters for Pain:

Answer 33

Psychological, spritual, sociocutural

characteristic of pain

physiologic responses

behavioral responses

affective responses

Question 34

General Assessment of Pain:

Answer 34

patient verbalization and description of pain

timing (onset, duration, pattern)

location of pain (superficical, deep, referred, radiating)

Intensity of Pain (severity-severe, moderate, mild)

Periodicity: (continous, intermittent, brief, transient)

Quality of Pain; (dull, stabbing, crushing, throbbing, sharp, burning, diffuse, shifting)

Chronology of pain:

Aggravating and alleviating factors (movement, positions drinking/eating, swallowing, stress, coughing, heat/cold)

Physiologic indicators of pain

behavioral responses

effect of pain on activities and lifestyle

Question 35

Pain Assessment Tools:

Answer 35

0-10 Numeric Rating Scale

Adult Nonverbal Pain Scale

Wong-Baker FACES

Beyer Oucher pain scale

CRIES pain scale

FLACC scale

COMFORT scale

Question 36

Safety Guidelines:

Answer 36

the patient is the only person who should press the button to administer the pain medication when PCA is used

monitor the patient for signs and symptoms of oversedation and respiratory depression

keep diary of pain medications to prevent under and overuse

monitor for potential side effects of opioid analgesics

Safety: avoid drinking, operating machinery, alcohol, or other CNS depressants

do not breastfeed without consulting provider

Question 37

Pain Management regimens for cancer or chronic pain:

Answer 37

give medications orally if possible

administer medications ATC rather than PRN

adjust the dose to achieve maximum benefit with minimum side effects

allow patients as much control as possible over regimen

Question 38

Numeric Sedation Scale:

Answer 38

S: sleep, easy to arouse: no action necessary

1: awake and alert; no action necessary

2: occasionally drowsy, but easy to arouse; no action necessary

3: frequently drowsy, drifts over to sleep during conversation; reduced dosage

4: somnolent with minimal or no response to stimuli; discontinue opioid, consider use of naloxone

Naloxone (Narcan) can be used to reverse effects of respiratory depression

Question 39

The WHO 3-step Analgesic Ladder:

Answer 39

Step 1: nonopioid (+/- Adjuvant)

Step 2: opioid for mild to moderate pain (+/- nonopioid, +/- adjuvant)

Step 3: opioid for moderate to severe pain (+/- nonopioid, +/- Adjuvant)

Question 40

Nonparmacologic: pain relief measures:

Answer 40

Distraction (ambulation, deep breathing, visitors, TV, games, prayer, music, pet therapy)

Humor

Music

Guided Imagery & relaxation (medication, yoga)

Cutaneous stimulation (massage, TENS, heat, cold)

Acupuncture

hypnosis

biofeedback

therapeutic touch

animal-faciliated therapy

Question 41

Pharmacologic Pain measures:

Answer 41

Nonopioid Analgesics:(acetaminophen and NSAIDS)
tylenol hepatoxic max- 4g/day
NSAIDS long term: GI bleeding

Opioids or narcotic Analgesics: (controlled substances: morphine, codeine, oxycodone, meperidine, hydromorphone, methadone)
- Side Effects: sedation, respiratory depression, N/V, constipation, urinary retention, altered mental processes, orthostatic hypotension, withdrawal/tolerance

Adjuvant Drugs: anticonvulsants, antidepressants, multipurpose drugs

Question 42

Diagnosing Pain:

Answer 42

type of pain

etiologic factors

behavioral, physiologic, affective responses

other factors affecting pain process

Question 43

Etiology:

Answer 43

Nociceptive:
type of Nociceptive pain
- cutaneous
-somatic
-visceral

Neuropathic:
damage from abnormal or damaged nerve pain
Ex: phantom limb pain, diabetic neuropathy
pins and needles, burning, shooting, intense

Question 44

Perioperative Stages:

Answer 44

Preoperative:
beings with decision to have surgery, last until patient is transferred to operating room or procedural bed

Intraoperative:
begins when the patient is transferred to the OR bed until transfer to the post anesthesia care unit (PACU)

Postoperative:
last from admission to PACU or other recovery area to complete recovery from surgery and last follow-up health care providers visit

Question 45

Classification of Surgical Procedures:

Answer 45

Urgency: elective, urgent, emergency

Risk: Minor or Major

Purpose: diagnosic, curative, preventable, ablative, palliative, reconstructive, transplantation, construtive

Question 46

Types of Anesthesia:

Answer 46

Anesthesia: loss of sensation in all or part of the body with or without loss

General:
administration of drugs by inhalation or intravenous route

Moderate Sedation/analgesia: (conscious sedation/analgesia) used for short-term minimally invasive procedures

Regional: anesthetic agent injected near a nerve or nerve pathway or around operative site

Topical and local anesthesia: used on mucous membranes, open skin, wounds, burns

Question 47

Three Phases of Anethesia:

Answer 47

Induction: from administration of anesthesia to ready for incision

Maintenance: from incision to near completion of procedure

Emergence: starts when patient emerges from anesthesia and is ready to leave operating room

Question 48

states of Anesthesia:

Answer 48

loss of consciousness

Amnesia (loss of memory)
analgesia (absence of pain)
relaxed skeletal muscles
depressed reflexes

Question 49

Informed Consent Information:

Answer 49

description of procedure and alternative therapies

underlying disease process and its natural course

name and qualification of person performing procedure

explanation of risks and how often they occur

explanation that the patient has the right to refuse treatment or withdraw consent

explanation of expected outcome, recovery, rehabiliation plan, and course of treatment

Question 50

Advance Directives:

Answer 50

Living Wills:
a legal document that expresses, in advance, a person instructions or preferences about future medical treatments particularly end of life care in the event the person loses capacity to make health care decisions

Durable Power of Attorney for healthcare:
a legal document that appoints a person (typically called a health care agent, but also a proxy, health care representative) to make decisions for the person n the event of incapacity (temporary or permanent) to make healthcare decisions

Do Not Resuscitate (DNR)

Question 51

Promoting Return to health: surgery

Answer 51

elimination needs

fluid and nutrition needs

comfort and rest needs

helping the patient cope

Question 52

Interventions to prevent respiratory complications:

Answer 52

monitoring vital signs

implementing deep breathing

coughing

incentive spirometry

turning in bed every 2 hours

ambulating

maintaining hydration

avoiding positioning that decreases ventilation

monitoring responses to narcotic analgesics

Question 53

Postoperative Assessment and Interventions:

Answer 53

every 10-15 minutes

respiratory status (airway, pulse oximetry)

cardiovascular status (blood pressure)

temperature

central nervous system status (level of alertness, movement and shivering)

fluid status

wound status

Gastrointestinal status (nausea and vomiting)

general condition

Question 54

TJC protocol:

Answer 54

prevent wrong site, wrong procedure, and wrong person

preoperative patient identification verification process

marking the operative site

final verification just prior to beginning the procedure, referred to as the time-out

Question 55

Medication Names:

Answer 55

Chemical:
provides exact descriptions of medical composition (N-Acetyl-para-aminophenol)

Generic:
the manufacture who first develops the drug assigns the name, and then it is listed in the U.S pharmacopeia (acetaminophen)

Trade:
also known as brand or proprietary name. this is the name under which a manufacturer markets the medication (look for @ or TM)
(tylenol, pandol, tempra)

Classification:
effect of medication on body system
symptoms the medication relieves
medications desired effects
(analgesia, antipyretic, stimulants)

medication forms:
solid, liquid, other oral forms: topical, parenteral, forms for instillation into body cavities

Question 56

Pharmacokinetics:

Answer 56

the study of how medications

enter the body

are absorbed and distrubted into cells, tissue, or organs

reach their site of action

alter physiological function

are metabolized

exit the body

Question 57

Types of Medication Action:

Answer 57

therapeutic effect:
expected or predicted physiological responses

adverse effect: unintended, undesirable, often predictable

Side effect: predictable, unavoidable secondary effect

Toxic effect: accumulation of medication in the bloodstream

Allergic Reaction: unpredictable response to a medication; anaphylatic reaction

Medication Interaction:
when one medication modifies the action of another

Question 59

Types of Orders in Acute Care Agencies:

Answer 59

standing or routine: administered until the dosage is changed or another medication is prescribed

PRN: given when patient requires it

Single (one-time): given one time only for specific reason

Now: when a medication is needed right away; but not STAT

STAT: given immediately in an emergency

Prescription: medication to be taken outside of hospital

Question 60

Medication Administration: Nurse Role

Answer 60

determining medication ordered are correct,

assessing patient ability to self-administer,

determining whether patient should recieve mediation at given time

cosely monitoring effect

cannot be delgated

includes patient teaching

nursing students cannot administer medications without supervision by a licensed RN

Question 61

Timing of Medication Dose Response:

Answer 61

therapeutic range

peak
trough
biological half-life
plateau
time-critical medications
patient teaching

Question 62

Oral Administration:

Answer 62

tablets, capsules, suspensions, exlixirs, lozenges

Sublingual Administration: under tongue

Buccal Administration: Cheek

Question 63

Parenteral Medication:

Answer 63

Subcutaneous Injection: subcutanous tissue

Intramuscular injection: muscle tissue

Intradermal Injection: corium (under epidermis)

Intravenous injection: vein

Intra-arterial injection:artery

Intracardial injection: heart tissue

Intraperitoneal injection: peritoneal cavity

Intraspinal injection: spinal canal

Intraosseous injection:

Question 64

Nursing Assessment: Medications

Answer 64

through the patients eyes (preferences, values, and needs)

History: Allergies, medications, diet history, patients perceptual or coordination problems

patient current condition (some illness place pt. at risk for adverse medication effect)

patients attiude about medication use

factors affecting adherence to medication therapy

patients learning needs, health literacy

Question 65

Nursing Evaluation: Medication

Answer 65

through the patient eyes…

partner with your patients
response to medication
ability to self care
identify barriers to medication adherence

Patient Outcomes:
use knowledge of the desired effect and common side effects of each medication to compare expected outcomes with actual finding

Question 66

Rights of medication administration:

Answer 66

6 Rights:
1. right medication
2. right dose
3. right patient
4. right route
5. right time
6. right documentation

11 Rights:
medication
patient
dosage
route
time
reason
assessment
documentation
response
educate
refuse

Question 67

maintaining patient rights:

Answer 67

A patient has the right to…

To be informed about a medication

To refuse a medication

To have a medication history

To be properly advised about experimental nature of medication

To receive labeled medications safely

To receive appropriate supportive therapy

To not receive unnecessary medications

To be informed if medications are part of a research study

Question 68

3 checks of medication administration:

Answer 68

Read the label.

First check: when the nurse reaches for the container or unit dose package

Second Check: after retrieval from the drawer and compared with the eMAR/MAR or compared with the EMAR/MAR immediately before poruing from the multidose container

third check:
before giving the unit dose medication to the patinet or when replacing the multi-dose container in the drawer or shelf

Question 69

Identifying the patient:

Answer 69

checking the identification bracelet

validating the patient name (first identifier)

validating the patient identification number, medical record number and/or birth date (second identifier)
comparing with MAR
asking patient to state his or her name if possible

Question 70

administering Medication:

Answer 70

check MAR with accuracy of the order

know information about the medication that you plan to administer (action, purpose, normal dose, route, side effects, time of onset, peak, nursing implications

perform assessment (review of lab values, pain, respiratory assessment, cardiac assessment prior to medication administer to ensure the patient is recieving the correct medication for the correct reason. Assess for contraindications

ensure correct dosage calculation. Double check, have another nurse verify calculation

gather medication from the pyxis (no-interuption zone)

make sure medication is not expired and barcode is intact

high alert medication needs a second nurse

hand hyigene

educate the patient about the medication before administering it, Answer questions regarding usage, dose, and special considerations

use at least 2 patient identifers before administration

scan patient bracelet

check for allergies, type of reaction, severity of reactions

scan medication

position patient for proper administration of medication

if oral medication, give with fluid

ensure patient took medication, never leave in the patient room

perform hand hygiene

determine response to medication; complete assessment and/or vital signs

check to make sure no adverse effects

Question 71

Medication errors-prevention:

Answer 71

report all medication errors

patient safety is top priority, when an error occurs

read all orders, instructions, and labels carefully

ask questions if you do not understand

do not allow anyone or anything to interupt you

double check all calculations

use at least 2 ways to identify patient

identify and report system issues

learn as much as you can about the medication you administer

Question 72

Oral Administration: how to give medication through a g-tube:

Answer 72

verify that the tube location is compatible with medication absorption

use liquids when possible

if medication is to be given on an empty stomach; at least 30 min before or after feedings

risk of drug-drug interaction is higher

Question 73

Topical Application:

Answer 73

Skin applications:

use gloves and applicators; clean skin first

use sterile technique if the patient has open wound

follow directions for each type of medication

Transdermal patch:
remove old patch before applying new

document the location of the new patch

ask about patches during medication history

apply a label to the patch if it is difficult to see

document removal of the patch as well

Question 74

Nasal Instillation:

Answer 74

spray
drops
tampons

Question 75

Eye Instillation:

Answer 75

avoid the cornea

avoid the eyelids with droppers or tubes to decrease the risk of infections

use only on affected eye

never share medications

Question 76

Ear Instillation:

Answer 76

instill eardrops at room temperature

have patient sit upright or lie on side

straighten ear canal: adults pull auricle upward and outward Child: down and back

use sterile solutions and aseptic technique

check for eardrum rupture if patient has ear drainage

never occlude the ear canal

Question 77

Vaginal instillation/rectal instillation:

Answer 77

suppositories, foam, jellies, creams

applicators used (wash with soap and water)

patient often prefer adminstering own vaginal medications and need privacy

suppository insert 7.5-10cm (3-4 inches) stay supine for 5 minutes

Question 77

Administering Medications by inhalations:

Answer 77

Pressurized Meter-dose inhalers (pMDIs)
need sufficient hand strength for use
may be used with a spacer

Breath Actuated metered-dose inhalers (BALs)
release depends on strength of patient breath

Dry Powered inhalers: (DPIs)
activated by patient breath
hold breath 5-10 seconds, release with pursed lips
rinse mouth with corticosteroid inhale

Question 78

Administering medications by irrigation:

Answer 78

irrigations cleanse an area, instill a medication, or apply hot or cold to injured tissue

irrigations most commonly use sterile water, saline, or antiseptic solutions on the eye, ear, throat, vagina and urinary tract

use aseptic techniques if there is a break in the skin or muscosa

use clean technique when the cavity to be irrigated is not sterile, as in the case of the ear canal or vagina

Question 79

How to Mix insulin:

Answer 79

accuracy is critical

roll cloudy insulin, never shake (causes air bubbles- less accurate)

verify with another nurse

wipe top of vials with alcohol swabs

trick to remember: RN or clear to cloudy

administer within 5 minutes

never mix lantus or levemir with other types of insulin

Question 80

Minimizing Patient Discomfort:

Answer 80

use a sharp-beveled needle in the smallest suitable length and gauge; position patient comfortably

select proper injection site

apply a vapocoolant spray or topical anesthetic

divert the patient attention from the injection

insert needle quickly and smoothly

hold the syringe steady while needle remains in tissue

inject medications slowly and steadily

Question 81

Subcutaneous Injections:

Answer 81

administer into the adipose tissue layer just below the epidermis and dermis

slower absorption from the IM injection

use 3/8-5/8 inch, 25-27 gauge needle

inject at 45-90 degree angle: for obese patient use a 90 degree angle

small volumes not more than 1.5 mL

do not massage site

rotate sites

Question 82

Intramuscular Injections:

Answer 82

faster absorption than subcutaneous route

many risks, so verify the injection is justified

angle of administration: 90 degrees

body mass index (BMI) and adipose tissue influence needle size selection

Amounts:
Adults: 2-5 mL (4-5 mL unlikely to be absorbed properly)
children, older adults, thin patients: up to 2 mL
small children and older infants: up to 1 ml)
smaller infants: up to 0.5 mL

Question 83

Intradermal Injections

Answer 83

used for tuberculin screening or allergy testing

tuberculin or small hypodermic needle

5-15 degrees with bevel of needle pointing up

small bleb appears

Question 84

Dorsogluteal injection:

Answer 84

not recommended because of proximity to sciatic nerve and major blood vessels

large amount of subsutaneous tissue

Question 85

Ventrogluteal injection:

Answer 85

safest for adults, children, and infant esp with large volumes

recommended with volumes greater than 2 mL

Volume: average 2-4 mL

flex the knee and hip to relax muscle

Needle size:
Adult: 1.5 inches
Child: 1/2-1 inch

index finger, the middle finger, and the iliac crest form v-shaped triangle
injection site is center of triangle

Question 86

Vatus Lateralis Injection:

Answer 86

used for adults and children

use middle third of muscle for injection

often used for infants, toddlers, and children receiving biologicals

Question 87

Deltoid Injection

Answer 87

small volumes and immunizations

Needle length: Adult 1-1.5
child: 1/2- 1 inch

Question 88

Z-Track:

Answer 88

z track method is recommended to minimize skin irritation by sealing the medication is muscle tissue

zigzag path seals needle track

medication cannot escape from the muscle tissue

change needle before administering medication

use a large muscle such as ventrogluteal muscle

the needle remains inserted for 10 seconds to allow medication to disperse evenly rather than channeling back up the track of the needle

release the skin after withdrawing the needle

Question 89

Preparing an injection from an ampule:

Answer 89

snap off ampule neck

aspirate medication into syringe using filter needle

replace filter needle with an appropriate size needles or needless device

administer needle

Question 90

Preparing An injection from Vial:

Answer 90

if dry, use solvent or diluent as needed

inject air into vial

label multidose vials after mixing

refrigerate remaining dose if needed

never put a dirty needle in a multi dose vial

clean multidose vial with alcohol swab

Question 91

Piggyback IV Administration

Answer 91

a small (25-250 ml) IV bag or bottle connected to a short tubing line that connects to the upper Y port of a primary infusion line or to an intermiitent venous assess

Question 92

Intravenous Bolus

Answer 92

Introduces a concentrated dose of medication directly into the systemic circulation

Advantageous when the amount of fluid that a patient can take is restricted

The most dangerous method for medication administration because there is no time to correct errors

Confirm placement of the IV line in a healthy site

Determine the rate of administration by the amount of medication that can be given each minute

Make sure the site is healthy

Question 93

Five Part of the Communication Process

Answer 93

Stimulus or referent

sender or source of message (encoder)

message itself

medium or channel commication

Receiver (decoder)

Question 94

Disruptive Interpersonal Behaviors

Answer 94

incivility

bullying:
horizontal violence
nurse bullying
negative communication between nurse and physician

aggressive behavior

organizational response to disruptive behavior

Question 95

Blocks to communication:

Answer 95

failure to perceive the patient as human

failure to listen

nontherapeutic comments and questions

using cliches

using closed questions

using questions containing the words “why” and”how”

using questions that probe for information

using leading questions

using comments that give advice

using judgemental comments

changing the subject

giving false assurance

using gossip and rumors

using disruptive interpersonal behavior

Question 96

Characteristics of effective and ineffective groups:

Answer 96

group identity

cohesiveness

patterns of interaction

decision making

responsibilty

leadership

power

Question 97

Interviewing Techniques

Answer 97

open-ended questions or comments

closed question or comments

validating questions or comments

clarifying questions or comments

reflective questions or comments

sequencing questions or comments

directing questions or comments

Question 98

SOLER:

Answer 98

S: sit facing the client

O: observe an open posture; keep arms and legs uncrossed to receive info

L” lean toward the client

E: establish and maintain intermittent eye contact

R: relax

Question 99

Forms of communication:

Answer 99

Verbal: (language ~words)

Nonverbal (body language)
facial expressions, touch, eye contact
postur, gait gesture
general physical appearance
mode of dress and grooming
sounds, silence (moaning, crying, gasping, sighing)
electronic communication

Question 100

Factors influencing Communication:

Answer 100

developmental level

gender

sociocultural differences

roles and responsibilites

space and territorality

physical, mental, and emotional state

values

environment

Question 101

CUS

Answer 101

I’m Concerned

I’m uncomfortable

This is Unsafe

Question 102

Developing Listening skills:

Answer 102

sit when communicating with a patient

be alert and relaxed and take your time

keep conversation as natural as possible

maintain eye contact if appropriate

use appropriate facial expressions and body gestures

think before responding to the patient

do not pretend to listen

listen for themes in the patient comments

use silence, therapeutic touch, humor appropriately

Question 103

developing conversation skills:

Answer 103

control the tone of your voice, know your face

be knowledgeable about the topic of conversation

be flexible

be clear and concise

avoid words that might have different interpretations

be truthful

keep an open mind

take advantage of available opportunities

Question 104

Rapport Builders:

Answer 104

specific objectives

comfortable environment

privacy

confidentiality

patient vs task focus

utilization of nursing observations

optimal pacing

Question 105

Dispositional traits:

Answer 105

warmth and friendliness

openness and respect

empathy

honesty, authenticity, trust

non-judgemental

caring

competence

Question 106

Factors taht promote effective communication:

Answer 106

dispositional traits

rapport builders

Question 107

Phases of Nurse Patient Relationship:

Answer 107

Orientation phase

working phase

termination phase

Question 108

Surgical Risks of Medications:

Answer 108

Anticoagulants: precipitate hemorrhage

Diuretics: electrolyte imbalances, respiratory depression from anesthesia

Tranquilizers: increase hypotensive effects of anesthetia agents

Adrenal Steroids: abrupt withdrawal may cause cardiovascular collapse

Antibotics in mycin group: respiratory paralysis when combined with certain muscle relaxants

Question 109

Surgical Risk Factors:

Answer 109

Smoking: respiratory problems and poor wound healing

Age; very young and older patient

nutrition: increases need for nutrients, thin and obese patients often protein and vitamin deficient

Obesity: Morality increaes due to reduction in ventilary and cardiac function

Obstructive sleep apnea (OSA)

Immunosuppresion: risk for infection after surgery

fluid and electrolyte imbalance: hypovolemia

Postoperative nausea and vomiting (PONV) 30% can have PONV, can lead to pulmonary aspiration, dehydration, arrhythmias, pull apart suture

Question 110

Patient Risk Factors and strengths:

Answer 110

developmental level

medical and surgical history

medication history

nutritional status

use of alcohol, illict drugs, or nicotine

activiites of daily living and occupation

coping patterns and support system

sociocutural needs

Question 111

Assessment: surgical

Answer 111

Health history (medical, surgical, developmental, implants, nutrition, alcohol/drugs, ADLs)

physical exam

risk factors and allergies

medication and treatments

pre-operative blood work and testing

teaching and psychosocial needs

determine postsurgical support and referrance

Question 112

Outpatient/ Same-day surgery

Answer 112

reduces length of hospital stay and cut cost

reduces stress for the patient

may require additional teaching and home care services for certain patient

older patients, chronically ill patient, patint with no support system

Question 113

Complication: surgery

Answer 113

hemorrhage

shock

thrombophlebitis

deep vein thrombosis

pulmonary embolus

atelectasis

pneumonia

surgical site complications