Final Exam Flashcards
What is essential to note for IV potassium?
NEVER push potassium
What is atelectasis?
collapse of the alveoli
How can we prevent atelectasis?
encourage coughing/deep breathing, incentive spirometer
What does poor skin turgor and dry mucous membranes indicate?
fluid volume deficit
what may happen to the blood pressure during fluid volume deficit? What about the HR?
decreased BP
tachycardia
How can we prepare a patient for an MRI?
remove jewelry or metal, remove transdermal medication patches and insulin pumps/implants
Case study:
Exhibit 1
Patient is irritable, agitated, restless.
Exhibit 2
Nurse assesses client room and hears alarm beeping, overhead light is on, and TV is turned to full volume.
Which sensory condition are they likely
experiencing?
sensory overload
what interventions should be implemented for fluid volume overload?
daily weights (same time, same clothes), for bed weight-1 gown, sheet, pillow, assess for weight gain, I & O s
Which assessments are needed for suspected fluid volume overload?
breath sounds, check pulse, edema, JVD
When is the STOP BANG assessment required?
to assess a pt for a need of sleep study r/t sleep apnea
After assessing a post-op patient, a nurse auscultates all 4 quadrants of the pts abdomen and hears no bowel sounds after listening to each for 5 mins, what does the nurse suspect?
paralytic ileus
Give 3 examples of individuals who are at high risk for CAUTI?
older adults, prolonged catheter use, and immune compromised
What interventions can the nurse implement to prevent CAUTI?
-sterile technique
-routine perineal care
-bag below bladder
-empty bag regularly
What should the nurse do if a patient requiring a blood transfusion states, “I’m Jehovah’s Witness and can’t take that?”
accept their refusal and document
What condition may a patient develop if atelectasis is not treated?
fluid builds up making a place for bacteria to cause pneumonia
What are the main indications of late stage hypoxia?
blue on lips and fingertips
What type of medication causes extravasation?
vesicant
Name the IV complication:
cold, pale, puffy
infiltration
Name the IV complication:
redness, warmth, pain, burning, streaking
phlebitis
what are the rights of medication administration?
med, dose, route, client, time, documentation
What type of order is needed right away, where you must stop what you are doing and perform the task?
STAT
What are some required components of a medication order?
patient name
medication name
dose
strength
route
specific instructions (frequency, take w/food, etc.)
reason for admin
provider signature
The nursing student asks the RN what PPE they need to put on for contact precautions, how should the nurse respond?
gloves and gown
What type of precaution requires face mask?
face mask (surgical)
What type of solution can be used with blood products?
0.9 % normal saline (this is isotonic)
How often does TPN tubing need to be changed to prevent infection?
every 24hrs
what symptoms may a septic pt present with?
fever >100.4 F
elevated HR
BP trending downward
What are s/s of sleep apnea?
daytime sleepiness, snoring, O2 drop while asleep, abrupt cessation to breathing
What instruction should be provided for a midstream urine collection?
- clean urinary meatus
- start peeing
- catch in cup from middle of stream, not the first drips
A patient with a healing wound is due for a dressing change. The nurse assesses clear-light yellow drainage, free of blood.
How can the nurse best document this finding?
serous drainage
what consideration must be made while wasting a narcotic (controlled substance)?
another licensed nurse (RN) must be witness
In addition to being incontinent, what else must a patient have to require a catheter?
perineal wound (not just incontinence alone)
What does the presence of a bleb/wheal indicate for an intradermal injection?
effective administration
what angle is indicated for an intramuscular injection?
90 degrees
Mrs. Parker hears the RN tell the nursing student, “give this injection at a 45-90 degree angle.”
What type of injection can Mrs. Parker suspect they are giving?
subcutaneous
This method is used for intramuscular injections to prevent the medication from leaking out of the muscle tissue.
z-track method
What type of injection is an insulin injection?
subcutaneous (45-90 degrees)
This type of drainage appears light pink and is watery.
serosanguineous
How should green, yellow wound drainage be documented?
purulent
what is known as the output of a stoma?
effluent
Which stage of sleep is the most restful portion and is the period of time where vivid dreams occur?
REM
what is a common sign of early hypoxia?
restlessness
Upon removing staples, the nurse notices the incision site pulling apart, what should they do?
this is dehiscence, they must stop
What are the benefits of colostomy irrigation?
increases quality of life
provides scheduled bowel movements
What should the nurse promote in patients to help thin secretions for pts with pneumonia?
increase fluid intake
Provide some examples of food that the nurse should encourage their pt to eat who is trying to promote wound healing?
beef, eggs, cottage cheese
What should TPN be administered through?
central line (device that terminates in a great vessel)
What electrolyte are bananas and potatoes good sources of?
K + (potassium)
What foods should be avoided on a low sodium diet?
junk food, canned food, and fast food
What foods should the nurse encourage for a client who has low calcium?
dairy, tofu, and broccoli
Nuts, seeds, fatty fish, and dark chocolate are foods high in which electrolyte?
magnesium
What condition may a client experience if TPN is discontinued abruptly?
hypoglycemia
What components are in lipid solutions?
fatty acids and additional calories
While preparing a lipid solution, the nurse notices a pepper like substance floating on the top, and the the contents look similar to a lava lamp. What should the nurse do?
The nurse should not use this solution. Do not try to mix it back together, get a new one.
What interventions can be implemented for the treatment of RLS (restless leg syndrome)?
limit caffeine and alcohol
and implement exercising
potential need for medication
What type of breathing may indicate hypoxia?
rapid, shallow w/dyspnea
Why should pts remain upright for 1 hr following bolus tube feedings?
to prevent aspiration
How can the nurse determine correct placement of the feeding tube?
aspirate gastric secretions (use pH indicator strip)
Why is it important to check the expiration date on enteral feeding solutions?
expired formula may promote transmission of microorganisms
What statement by the RN to the new grad nurse demonstrates the correct rationale for tube-feeding formula to be at room temperature before administration?
“cold formula causes gastric cramping and discomfort”
How can we promote client comfort and autonomy for vaginal installation medication administration?
ask them if they are able to do it on their own
What condition is excessive daytime sleepiness often associated with? What is the treatment for this?
sleep apnea
CPAP
Stage this wound:
skin intact, nonblanchable erythema
stage 1
Identify the wound stage:
full skin loss w/possible muscle, bone, or tendon or tunneling
Stage IV
Which pressure injury stage is marked by full skin loss, damaged subcutaneous tissue, and potential for visible fat?
Stage III
Which stage of pressure injuries may look similar to a blister, but no fat tissue is visible?
Stage II
The patient has a very dry appearing wound, what type of dressing may the nurse prepare to administer?
hydrogel or hydrocolloid
The patient has a foul smelling wound with stringy yellow exudate, what type of wound dressing would the nurse prepare to apply?
Aquacel Ag (silver)
What is orthopnea?
SOB while lying down
A patient is newly prescribed take home O2 via nasal cannula, what are some teaching points the nurse should make?
NO smoking with O2
cotton fabric only
heat sources >10ft away
caution not to dent canister
While obtaining the pts BP, the nurse notices spasm/contraction of the hand.
Which electrolyte change can the nurse MOST likely prepare to treat?
hypocalcemia
What is the nursing priority for central lines?
sterile technique
Which statement by the new grad nurse BEST demonstrates understanding of how to prevent speed shock?
giving medications at their recommended push rate
What s/s may indicate speed shock?
facial flushing, irregular pulse, headache, hypotension, LOC, cardiac arrest
Immediately following administration of IV med administration the nurse assesses facial flushing and hypotension, what actions should the nurse take?
this is speed shock, the nurse should clamp IV, notify MD, apply O2 if indicated, and continually monitor vital signs
Why should we prep the feeding tube with enteral feeding solution prior to administration the feeding solution?
prevents excess air from entering GI tract once the infusion begins (less discomfort)
What is a priority nursing intervention for a client with impaired cognition receiving enteral tube feeding?
gastric residual checks, as this decreases the risk of aspiration
