Final Flashcards
1
Q
How do you use an IS?
A
Breathe in slow amend steady and hold it. Make a good seal on the mouthpiece, keep the ball in between two lines
2
Q
Can a pt share an IS?
A
No
3
Q
What is not allowed for an MRI?
A
Metal
4
Q
List some things that are a safety risk for an MRI
A
Jewelry, med patches, implants
5
Q
Is getting an MRI safe if a pt has a pacemaker?
A
They should have a medical implant card saying it is safe
6
Q
If a pt has any kind of implant or hardware in the body, what should they carry for an MRI?
A
MRI safety card clearing them to get one- the metal is not a hazard
7
Q
What should the nurse do if she cannot confirm a pt’s implant is safe for an MRI?
A
Reschedule the MRI until safety can be confirmed
8
Q
What’s are the types of wound drainage?
A
Purulent, sanguinous, serous, and serosanguinous
9
Q
Describe the appearance of serous fluid
A
Clear
10
Q
Describe the appearance of sanguinous fluid
A
Bloody
11
Q
Describe the appearance of purulent drainage
A
Thick, green/yellow (pus)- can be thick and have an odor- indicates infection
12
Q
Describe the appearance of serosanguinous fluid
A
Clearish with a brown/red/pink tint- can be considered normal post-op
13
Q
Describe slough
A
Sticky,stringy, yellow/green mostly covering the perimeter of a wound
14
Q
Describe eschar
A
Black, leathery covering wound bed
15
Q
What is granulation
A
Healing of the tissue and wound bed, good
16
Q
What is the acronym for wound care
A
BED
17
Q
What does BED in wound care stand for?
A
Bacteria, exudate, debridement
18
Q
Do you need BED for all wounds?
A
Yes, the more information, the better the wound are will be
19
Q
Do you have to use BED In order in wound care?
A
No
20
Q
What kind of wound would you use hydrogel /hydrocolloid?
A
Dry
21
Q
What kind of dressing would you use for a wet, draining wound
A
Alginate
22
Q
What is the absorbance capability of alginate?
A
Absorbs up to 20 times it weight
23
Q
Do you wet the alginate dressing before applying it?
A
No, it will inhibit the absorbent properties
24
Q
What kind of dressing would you use for an infected wound?
A
Silver, it is an antimicrobial agent
25
What are the IV complications?
Thrombophlebitis, phlebitis, infiltration, extravasation
26
Describe infiltration
Area will be cold, puffy, pale, but not painful
Medication escaped vein into surrounding tissues
27
Describe phlebitis
The vein becomes irritated by an infusion- too fast, cold,etc
Area will look red, warm, and may have streaking
Phlebitis scale 0-4
28
Describe extravasation
Vesicant (damaging) mediation escapes the vein into the surrounding tissues causing necrosis
I.e. chemo, phenergren
29
Thrombophlebitis
A blood clot in a vessel that can result in dangerous events if not treated immediately (MI,CVA,etc)
30
What is the phlebitis scale?
0-no pain, no appearance changes
1- pink but no pain
2- pink and warm with some pain
3- red, painful,possible streaking-can be palpable
4- red, warm, painful, obvious streaking, palpable veinous cord >2.54 cm purulent drainage
31
Z-track method is used for
IM injection
32
Pushing an injection rate
1mL/10 sec
33
Infection sites for IM injections
Deltoid, vastus lateralis, ventrogluteal
34
How to locate injection site for the deltoid location
Find acromion process, 2-3 finger widths down
35
How to locate the injection site for the ventrogluteal injection site
Find the greater trochanter and iliac crest
Palm on greater trochanter , fingers towards umbilicus and iliac crest- in between the “V”
36
6 rights of medication administration
Right person, time, medication,dose, route, documentation
37
Degree of injection for an IM injection
90
38
What is the Z-track method
Displacing the skin to prevent leakage of irritating or discoloring meds into subcutaneous tissue and prevent leakeage into needle track; this also eliminates discomfort
39
Landmarks for vastus lateralis injection site
Hip and knee- go in between both joints
40
Best location for a large volume of medication in an injection
IM- ventrogluteal
41
Best locations for a viscous medication via injection
IM- ventrogluteal
42
Small amount of medication(i.e. flu vaccine), best location for injection?
Deltoid
43
What are the pt rights of medication administration?
Right to be informed about a medication, right to refuse a medication, right to be properly advised about experimental nature of medication, right to receive labeled meds safely, right to receive appropriate support therapy, right to not receive unnecessary medication, right to be informed if meds are part of a research study
44
Angle of injection for subcutaneous injections
45-90 degrees, changes based on client’s available adipose tissue
45
What kind of injections are given subcutaneously?
Insulin, blood thinnner (lovenox/enoxaparin), heparin
46
Do you z-track subcutaneous
No
47
Do you aspirate an injection?
No
48
Routes of medication administration
Oral(buccal and sublingual), parenteral (IV,IM,ID,SC), specialized (epidural, intractable, intraperitoneal, intrapleural, intraarterial), topical (skin and mucous membranes) inhalation, intraocular
49
Define topical medications
Skin and mucous membrane based administration of medications
50
What are the types of oral mediations
Sublingual and buccal (or swallowed whole)
51
What are the parenteral medication types?
ID,SC,IM,IV
52
Are eye drops clean or sterile?
Sterile
53
Are nasal sprays clean or sterile?
Clean
54
Are nasal drops clean or sterile?
Sterile
55
What kind of needle is used or ID injection?
Tuberculin
56
Which insulin do you inject air into first
NPH (cloudy)
57
Which insulin do you draw first ?
Regular (clear)
58
Who reports an error?
Anyone who finds it
59
Controlled med—> waste unused amount
Witness needed-another nurse (if you are licensed to give it, you can witness)
60
PRN order
When pt needs it, i.e. pain medication
61
Sharps go….
Into a sharps container
62
If the sharps container is mostly full,
Close it and find another one
63
STAT order
Immediately, emergency use
64
Where do you put a controlled med to waste
The designated container with a witness
65
Standing order
Certain time, there until the order is changed of d/c
I.e. BP med
66
One-Time order
One time for a specific reason i.e. anxiety meds before MRI
67
When would someone need a catheter? (Foley)
Acute Urinary retention, surgery(prolonged surgery/urologic surgery/adjacent structures), loss of continence with a sacral/perineal wound, hospice/comfort measures for end of life, require strict prolonged immobilization, acute bladder outlet obstruction, need for accurate measure of output in critically ill
68
How to prevent a CAUTI
Maintain a closed system, sterile aseptic technique insertion, standard precautions, proper peri care, using when appropriate indications are present, only using it as long as it is needed, maintain unobstructed urine flow, proper. Hand hygiene, change whole system Q 30 days, hang bag below bladder on unloveable part of bed
69
How often should the whole Foley catheter system be changed?
Every 30 days
70
When mixing meds in a vial and ampule, which med do you draw first?
VA
Vial then ampule
71
Do you shake the NPH solution to make sure the medication is dispersed?
NO- roll it
72
What insulins should never be mixed
Long acting
Lantus or levemir
| glargine and detemir
73
What is a clean catch urine sample
“Midstream”
Used for C&S
Clean peri area, start to pee, stop, then pee and catch
74
Random specimen for urine sample
UA and Microanalysis, anytime
75
First morning specimen urine
8 hour urine collection
Most concentrated, higher elements of cellular components and protein if present
76
Most common reason for an 8 hour urine collection
Pregnancy tests
77
Timed specimen collection
24-hour urine collection
Empty bladder completely first and then start collecting EVERY DROP at “start time”,must start over if even a drop is lost
78
Timed specimen collection
Must be on ice in a biohazard bag before taken to the lab labeled
79
Steps for glucose monitoring
Hand hygiene
Identify client-2 identifiers
Gloves
Scan badge
Scan pt
Compare screen with bracelet
Cleanse pt finger (ask preference)
Let dry for 10 sec
Insert strip into glucometer
Prick outside of finger pad
Wipe waste away
Let blood run into test strip- lay glucometer flat
Hold pressure on clients finger
Bandaid if needed
Discard lancet and used supplies
Clean glucometer
Doff gloves
Hand hygiene
80
How do you evaluate sleep?
Subjective- ask the pt
81
Sleep apnea
Air passages relax when asleep-airflow blocked and breathing stops
S/s=excessive daytime sleepiness, snoring, headaches
Dx with sleep study
CPAP=tx
Use STOPBANG Assessment
82
Insomnia
Cannot fall asleep and stay Asleep
Medications are the last resort
Teach sleep hygiene first
83
Narcolepsy
Falls asleep uncontrollably- cataplexy=paralysis, no control
Meds can treat not cure
Helmets outside if severe
Worsens with strong emotions
84
CAP
Community acquired pneumonia
Risks=old age, immunocompromised,smoking, vaccination status, children
85
HAP
Healthcare associated pneumonia
Risks= ventilator, increased age, immunocompromised, aspiration
86
Oxygen safety
Avoid heat, smoking, and dropping it
87
Hypoxia
Early-agitation, restlessness, pallor
Late-cyanosis, LOC
88
Wound stages
Unstageable, 1-4, deep tissue injury
89
Stage 1 wound
erythema, non-blanchable skin intact
90
Stage 2 wound
erythema, partial thickness loss of epidermis
91
Stage 3 wound
partial thickness loss going into the dermis but no underlying structures exposed
92
Stage 4 wound
ful thickness skin loss past the dermis, bone, muscle, etc may be visible or palpable
93
Unstageable wound
cannotbe staged bc the wound bed is not visible- covered by eschar or slough
94
What kind of diet should a pt with a healing wound be on?
High protein
95
What are the drain types
J-Pratt, hemovac
96
What is important about a wound vac
Seal of occlusive dressing - promotes granulation of tissue and healing with neg pressure
97
How do you remove staples and sutures
Clean
Start with 2nd one, remove every other one until done to avoid dehiscence
Cut stitch at knot and remove by pulling on the long part
98
What happens if a wound dehisces?
Stop immediately and notify the provider that the wound has opened again and needs to be closed
99
New ostomy education
How to clean- soap and water no alcohol
Avoid high fiber (ileostomy) and increase fluids (ileostomy)
No laxatives - occluded or dehydrated
Liquid/paste output-ileostomy
Colostomy output-solid
100
What is a large issue with new ostomies?
Client acceptance
101
Complications of ostomies
Necrosis, candidiases, caput medusae, prolapsed, collapsed
102
Ice counts as
1/2 cup
103
How many mL is in an ounce?
30mL
104
How many ounces are in one mL?
1 oz
105
Foods high in potassium
Bananas, avocados, white potatoes
106
Foods high in sodium
Canned/processed foods
107
Foods high in magnesium
Nuts, seeds, fatty fish , dark chocolate
108
What two signs indicate hypocalcemia?
Chovstek and trousseau
109
Chovstek sign
Tap cheek, if twitch, calcium is low
Positive test= hypocalcemia
Negative test=no imbalance
110
Trousseaus sign
Carpal spasm
BP cuff or tourniquet and watch for spasm, dont need to keep inflating once spasm occurs
111
How do you treat ascites?
Sit them up, increase fluids (if dehydrated), thoracentesis and paracentesis
112
S/S FVO
Thready pulses, HTN, edema, crackles in the lungs, weak peripheral pulses,JVD, excessive weight gain
113
S/S FVD
Poor skin turgor, flat neck veins, dry mucous membranes, bounding pulses,tachycardia, hypotension
114
Delegation
The act of dividing tasks to other people while still maintaining responsibility/accountability for the outcomes
115
What should be kept in mind while delegating?
Is this the safest person for the skill?
Scope of practice
Trained for this task?
Experience
Client AND worker safety
116
Pain scales
Wong-baker, FLACC, numeric
117
Wong-baker scale
Pain scale using faces for children or those with difficulty verbally expressing
118
FLACC scale
Face, legs, activity, cry, consolability
119
Who is the FLACC scale used for?
Unconscious
120
What is the greatest determinant of pain?
The pt
121
Chronic pain is always psychological
False
122
Chronic pain always leads to addiction and abuse of meds
False
123
Breakthrough pain
Occurs after controlled med wears off (i.e. morphine/opioids), can be treated with “lighter” meds like NSAIDs
124
Do long-term meds always lead to addiction?
No
125
Addiction
Physical dependence on a medication or substance- an individual will put themselves, loved ones, or family in harms way intentionally for a substance or the effect
126
Dependence
Body produces symptoms without given substance
127
Clients who abuse substances overreact to discomforts
False
128
The amount of tissue damage in an injury does not accurately indicate pain intensity
True
129
If a client cannot speak, they cannot feel pain
False
130
What are the characteristics of pain
Onset & duration
Location
Intensity
Quality
Pattern
Relief measures
Contributing symptoms
Effects of pain on the client
131
Two mnemonics for pain assessment
OLD CART and PQRST
Onset, location, duration, characteristics, aggravated factors, radiation, tx
Provoked, Quaity, Region/ radiation , Severity, Timing
132
Pain scales determine the ______ of pain, not the _______
Presence, intensity
133
what is an NG tube
Nasogastric tube
Can be placed bedside
134
indications for enteral feeding
Cannot eat bc of surgery, injury, disease process
Nutritional deficit from reduced food digestion, even when physically capable of eating
Impaired swallowing/gag reflex
135
What is a contraindication for having enteral feeding?
Tube in the brain - a brain shunt (drains in back of throat, tube feeding will harm pt)
Facial deformities (facial fractures)
136
What is a bolus feeding
“All at once”orders tell volume and time- aspiration risk!
Make sure client sits up for an hour after feeding for gravity to help with aspiration risk
given thru G tubes
137
Who does the nutritional needs assessment?
Dietician / practitioner
138
Continuous feedings
XML/hr for 24 hours
PUMP needed
30 degrees minimum HOB
139
What is the difference between Dobbhoff and NG
Dobbhoff has a guide wire and is weighted to go through stomach sphincter and anchor in jejunum
NG ends in stomach
140
PEG and PEJ are….
Long-term solution, surgically implanted
141
NG and Dobbhoff tubes are
Short-term solutions
142
G tubes-ending in stomach can be used for
Bolus or continuous feeds
143
With jejunum lines, nutrition is
Continuous feeds bc there is no “holding tank” or digestive enzymes/ secretions in jejunum
144
What color bag, syringes, and tubing mean enteral nutrition
Purple
145
Tube-feeding formula should be kept at
Room temperature to avoid cramping and bloating
146
What technique do you use to prepare and hang feeding formula
Aseptic technique
147
What is the maximum hang time for formula in an open system, why?
8 hours, increased risk of bacterial colonization bc of high sugar
148
When do you check gastric residual volume for each feeding
Bolus-right before next bolus, intermittent- before next feeding, and every 4-6 hours initially for continuous
149
How do you check for gastric residual?
Draw up 30 mL of air into syringe and connect it to the feeding tube,listenfor air, pull back slowly, and aspirate the total amount of gastric contents
Return aspirated contents to stomach unless the volume exceeds 250mL or other specified amount
150
When do you hold a feeding?
If gastric residual is 250mL or greater - hold for one 1hr and recheck, if still over 250mL, do not give second feed, report to HCP and expect continuous feeding order - not tolerating bolus
151
For immunocompromised pts, what is used to flush tubes
Sterile water
152
What do you flush feeding tubes with
30mL of tap water, unless specified otherwise
153
Bolus feeding
Feed 30 min-1hr
Sit up for 1 hr after
Never put more than 8 hrs of feed in a bag
8 hr tubing
154
Continuous feeding
24 hrs
30 degree HOB
Change tubing and feed q 24hrs
155
Open feeding system
Disconnected tubing or add anything
Good for 8 hours
Pour feed into bag (open)
156
Closed feeding system
Closed canister and spike
24 hrs then change
157
Any questions about TF tubing dates, times, etc
Replace it
158
Administering medications through an enteral tube
Flush tube with at least 15mL of sterile water using 60mL syringe
Draw up mediation in 60 mL syringe
Push meds or allow gravity free flow
Administer each med SEPARATELY followed by 15-30mL water
After all meds administered, flush tube with 30-60mL water
Restart feed in when appropriate
159
How can you prevent cramping with enteral feedings
Room temp feeding, rate change (bolus to continuous if needed), no overfeeding
160
what do you check for with catheter insertion after verifying the client’s identity
Allergies to betadine or iodine
161
24 hour urine collection must
Be on ice at all times, “start time” and “end time” without a single DROP missing!
162
what is a huge concern for enteral nutrition
Hyperglycemia (high in glucose), infection and bacterial growth
163
when does REM begin?
90 min after stage 1
164
What is the REM stage
Real resting phase-best sleep
Absent muscle tone, increased gastric secretions, vivid dreaming , difficult to arouse
165
How can you promote sleep?
Cluster care, environment control, save invasive procedures for the daytime
166
Ostomy complication- necrosis
Most common post-op
Stoma is black- surgical fix
167
candidiases ostomy complication
Moisture and bacterial growth (host immunosuppression)
Keep it dry
Porous tape
Antifungal powder
168
Caput medusae Ostomy complication
Liver disease pts
Hypervascularity
No tape-Vaseline for adhesive
Soft pouching system
Risk for bleeding
169
Who qualifies for colostomy irrigation
Increase quality of life , scheduled timing
Anyone with no GI or mental issues
170
pts with an ileostomy are at high risk for
Occlusion bc lumen=narrow
Chew well and avoid high fiber foods for 6 weeks then intro one at a time
dehydration
171
Normal color for ostomy stomas
Red, “beefy”
Like the rolled end of a sock
172
Mucocutaneous separation ostomy complication
Skin and fat separating, bacteria seeps into gaps-infection
Causes-malnutrition, steroids, infection, radiation
Tx=surgical, fillers
173
Stomal retraction
Stoma pulled in sided out
Weight gain, or too tight surgically (thick abd wall)
174
Stomal stenosis
Lumen collapse
Stool softeners, may require surgical intervention
175
Stoma hernia
Additional bowel loops trapped
Surgical technique, poor stomach placement
Age (elderly)
Hernia support belt, flexible pouching system, d/c irrigation
176
Prolapsed stoma
"dangling out"
One piece pouncing system needed
Reduce with cool packs and Lying on back, not painful but pouching-difficult
Reduce abd pressure
177
Weartime for ostomy bags
3-14 days unless leaking, soiled, hurting, bleeding—>Change it
178
Pectin skin barrier
Short time wear, not used for urostomies bc urine dissolves it
179
Skin barrier paste for ostomies
Paste is NOT an adhesive, it IS a caulk
More is NOT better-> contains alcohol=drying to skin
Not used on premature babies bc of high alcohol content
180
Skin barrier powder
Only used on eroded, moist skin
D/c after skin heals
181
Odor elimination for ostomies
DO NOT USE ASPIRIN TAB= excess gas production and bag explodes
Drops when pouch is emptied
Spray in room
Filters with charcoal
182
Exudate management
Maintaining or providing a moist wound environment while controlling excess wound drainage
183
Transparent film dressing helps to
Maintain or provide moisture to a wound
184
Ex of transparent film
Tegaderm
185
Wound care products to absorb wet wounds
Alginate (most absorbent)
Foam
NaCl dressing
Wound drainage collector
Wound vac (neg pressure therapy)
186
How to keep a wound “balanced”, not wet or dry
Moist saline gauze
Tegaderm
187
How often do you change dressings
Q 12 hrs- 3 days unless saturated then change
188
Autolytic debridement
Occlusive dressing, wound enzymes clean itself
189
Mechanical debridement
Flushing and cleaning by hand
190
Enzymatic debridement
Introduce wound wash to help as we clean to breakdown things
191
Sharp/excisional
Surgical debridement
192
Bio debridement
Maggot therapy; aseptically grown in lab, short life span
Only for difficult healing wounds
193
STOPBANG assessment
Snoring?(loud?)
Tired?(during day)
Observed?(witness stop breathing)
Pressure?(HTN?)
BMI?(>35)
Age?(>50)
Neck size?(men=>17in fem=>16)
Gender? (Male=risk)
194
STOPBANG risk levels
Low= yes to 0-2
Intermediate= yes to 3-4
High= yes to 5-8
195
Biotes breathing
Brain issues
196
Kussmaul’s breathing
DKA
197
describe Biote’s breathing pattern
Apnea, rapid breathing, apnea
198
Describe kussmaul’s breathing pattern
Maximum inhalation and maximum exhalation at a rapid rate
199
Describe Cheyne stokes breathing pattern
Apnea, gradual increase, gradual decrease, apnea
200
Cheyne stokes
Cardiac issues
MI, HF
201
ABCDE of pain management
A- ask about pain regularly
B-believe the client abt pain
C-choose pain control appropriately
D- deliver interventions timely logical and coordinated fashion
E-Empower clients and families to control course to greatest extent
202
Reversal agents
Opioids-Naloxone
Benzos-flumazenail
Malignant hyperthermia-dantrolene
203
Types of anesthesia
Local (site), general (out out), conscious sedation (maintain airway themselves, be ready to stabilize if needed)
204
informed consent
Over 18, right mind, not under influence , disabilities (if still in right mind ) can consent, we accommodate to them
205
Role of circulating RN
Maintain safety of client
Sterile filed, monitors
206
Periopertive complications
DVT, paralytic ileum, post op PNA
207
Tx DVT
TEDS, SCDs, lovenox
208
Tx paralytic ileus
Bowel sounds x4–> 5 min listen, gas? BM? Surgical
209
Tx post-op PNA
IS, deep breathing and coughing exercises, early ambulation
210
Classifications of surgery
Urgent, elective, emergent
Minor/major
211
Score on aldrete tool for ICU discharge
8 or higher
212
Aldrete tool
Scoring pt to discharge from ICU to PACU
213
Delirium vs dementia
Delirium- short term, after surgery
Dementia- progressive, long-term condition
214
Difference between delirium and dementia
Speed of onset
215
Hypertensive crisis
Over 180/100
216
Isotonic solution
NS (0.9 NaCl)
LR
D5W(in bag)
217
Hypertonic solutions
D10
2% NaCl
3% NaCl
218
Hypotonic solutions
0.45% NaCl
0.33% NaCl
219
Isotonic solutions effect on cell
Same, even transfer of fluid
220
Hypotonic solution effect on cell
Cell swells
221
Hypertonic solution effect on cell
Cell shrinks
222
What patient conditions are contraindicated for LRs
Liver and renal failure pts
223
What condition can isotonic fluids be used for
LR for burns and electrolyte imbalances
224
What condition can hypertonic fluids be used for
increased intracranial pressure (ICP) bc it pulls fluid out of the cell
225
What condition can hypotonic solution be used for
Extreme dehydration, pulls fluid into the cell
226
IV site selection
Start low and go up, do not use hand for vesicant medications , avoid limbs with fistulas, past mastectomy or lymphectomy, stroke unilateral weakness
227
Hypoglycemia s/s
Weakness, dizziness, shakiness,clammy
228
What do you do if TPN tube falls to floor or did not arrive on time?
Abruptly d/c current and/or use new tubing and run D10 while waiting for the new mix
229
Hyperglycemia s/s
Polydipsia, polyuria, polyphagia
230
Contents of TPN
Vitamins, electrolytes, sugar, minerals
231
TPN looks like
Lemon lime Gatorade
232
TPN is given at
Room temp, take out of fridge 1 hr before administration
233
How is TPN given
Through a central line (terminates in a great vessel), sterile
234
Lipids for TPN look like
Milk in a bag
235
Do you give lipids through a central line?
Yes, but also though a peripheral line
236
Lipids have
Essential fatty aids, calories
237
Can you shake lipids to mix bc it looks separated or “cracked”
No, get a new bag
238
Complications with TPN infusion
Infection: fever, increased WBC, redness, drainage
Blood glucose: monitor for hyperglycemia (high in sugar), if stopped abruptly- hypoglycemia risk, start D10
239
What electrolytes are in LR
Magnesium, sodium, potassium, calcium
