FinalExam2 Flashcards
What type of medication administration would we instruct the client to place between the gum and cheek?
buccal administration
What is important to tell the client for sublingual and buccal medication administration?
don’t swallow and allow to fully dissolve
What are the types of orders?
written (hand or electronic), verbal, and telephone
What would be an appropriate action if a nurse has a problem reading a providers medication order?
call the provider to verify the order
What are the 5 rights of delegation?
task
circumstance
person
direction/communication
supervision
True or false: Patient should breath out while using incentive spirometer.
False, you should breathe in, as this allows lungs to expand, preventing atelectasis
How should patient sit during IS use?
upright
Steps for using incentive spirometer (IS):
-6 steps
- sit straight
- exhale fully
- seal mouth on mouthpiece
- slow/steady inhale until unable
- hold breath at least 5 secs
- slow exhale
For a patient receiving tube feedings when can medication be given?
30 mins before or after feedings
How can infection be prevented by the nurse during suture removal?
clipping the shorter side and avoid pulling the knot under skin to ensure that the least amount of the suture goes under the skin as possible
Before inserting the feeding tube, what assessments would be
appropriate to determine the patient’s risk for aspiration?
mental status, gag reflex, and ability to swallow
When aspirating *continuous enteral gastric contents, how should they appear?
curdled enteral formula with PH of 5 or higher
What is the purpose of capillary blood glucose?
determine/monitor blood glucose levels of clients at risk for hyperglycemia or
hypoglycemia
What must be avoided when collecting the stool specimen?
Do not allow specimen to come in contact with water or urine
What should be utilized to prevent other personnel from discarding urine during a 24hr urine specimen collection?
signage noting that a 24 hr collection is currently in place
What action must the nurse take if a patient discards urine during a 24hr urine specimen collection?
restart the collection process
What is priority for the nurse to ensure during a lumbar puncture?
that the patient does not move
How often does formula in an open tube-feeding system have to be changed?
every 8 hrs
How many mL in one ounce?
30 mL
What PPE should be used for bacterial pneumonia?
surgical mask
What type of solution should NOT be used during ostomy care?
NO alcohol, use warm water not hot
What type of precautions may be used for the following:
- leukemia
-oncology
-immunocompromised
-HIV/AIDs?
protective/reverse isolation
When may airborne precautions be used?
TB, Covid, and disseminated shingles
What is used for airborne precautions?
N95 and negative pressure
What does the BED model stand for in wound care?
bacteria
debridement
exudate
What nursing interventions are needed for an evisceration?
sterile towels soaked in warm saline to decrease bacteria invasion and drying of the organs
What position should a pt be in if an evisceration occurs?
low/semi fowlers with knees gatched
Ostomy complication:
-can be caused by medications (antibiotics, cancer, chemo)
-moisture can contribute
-immunosuppression
candidiasis
use antifungal powder, promote dry environment, porous tape
What patients may experience caput medusae?
this is an ostomy complication in those w/ liver disease
What interventions can be implemented for caput medusae of the stoma?
Vaseline to pouch, very gentle removal/changes because they are at serious risk of bleeding
Name that stoma complication:
-cause: malnutrition, steroids, radiation
-treated with fillers
mucocutaneous separation
What is an ostomy complication that would likely occur soon after surgery if circulation of the stoma is compromised due to surgical technique or thick abdominal wall?
stomal necrosis
This ostomy complication occurs due to weight gain, surgical technique, and/or weight gain.
retraction
What may those with stomal stenosis require due to the impaired size of the lumen?
stool softeners
What should be used for voiding if a prolapse of the stoma occurs?
one piece pouch system
and use cool packs + lying on back
How long can we use peripheral IV?
1 week
Which venous access device can be used for 1-4 weeks?
MLC (midline)
What ratio can be used for the dilution of IV potassium (we don’t do this, this is done in pharmacy)?
1 mEq of potassium to 10 mL of solution
what is the maximum IV potassium rate?
10 mEq/hr
Which IV complication may present w/ resp distress, unequal breath sounds, weak pulse, inc CVP, dec BP, confusion, disorientation, LOC?
air embolism
Which IV device can be used for weeks to months?
central line
