Fundamentals

Question 1

Gastrointestinal

• Have saline available for flush; do not start fluids until positive confirmation of placement (CXR).
• Position? trendelbeurg distend veins (acts as a tourniquet)
• If air gets in the line what position do you put the client in?

Left side trendelenburg (supine will make bubble travel to lung) Lying on left side traps bubble to left side bottom of heart

• When you are changing the tubing, how can you avoid getting air in the line?

Clamp it off
Valsalva
Take a deep breath and HUMMMMMM (increases thoracic pressure)

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down.
If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure.

Answer 1

central catheter tubing changes

Question 2

See Flash card hero

Answer 2

Hyperalimentation (total parental nutrition) (TPN)

Question 3

• A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection.
• Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign
• A “shift to the left” means that an increased number of immature neutrophils is present in the blood.
• 2. A low total WBC count with a left shift indicates a recovery from bone marrow depression or an infection of such intensity that the demand for neutrophils in the tissue is higher than the capacity of the bone marrow to release them into the circulation.
• 3. A high total WBC count with a left shift indicates an increased release of neutrophils by the bone marrow in response to an overwhelming infection or inflammation.
• 4. A “shift to the right” means that cells have more than the usual number of nuclear segments; found in liver disease, Down syndrome, and megaloblastic and pernicious anemia.
• Monitor the WBC count closely in clients receiving chemotherapy because of the risk for neutropenia.

Answer 3

white blood cell (WBC) differential with a shift to the left and right

Question 4

• Rate at which erythrocytes settle out of anticoagulated blood in 1 hour
• A nonspecific test used to detect illnesses associated with acute and chronic infection, inflammation, advanced neoplasm, and tissue necrosis or infarction

Answer 4

Erythrocyte sedimentation rate ESR

Question 5

• An advance directive is a legal document that’s used as a guideline for life-sustaining medical care of the client with an advanced disease or disability who can no longer indicate his own wishes.
• The advance directive is a document that allows the client to give directions about future medical care or to designate another person to make medical decisions if and when the client loses decision-making capacity.
• By initiating a code blue, the nurse didn’t follow the client’s advance directive and DNR order.
• The physician was correct to follow the client’s wishes and stop resuscitation efforts. The physician had the authority to stop the code.
• An advance directive should be part of the client’s medical record. The client should review the document with the physician at every admission because some conditions may be reversible and temporary, making portions of the advance directive inappropriate. Simply telling the client that the document will be included in his permanent record doesn’t address the need to review the directive with the physician. Advance directives are appropriate for clients of any age.
• Written document recognized by state law that provides directions concerning the provision of care when a client is unable to make his or her own treatment choices; the two basic types of advance directives include living wills and durable powers of attorney.
• This document can include
  
  • living will
    
    • Living will: lists the medical treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill.
    • instructs the physician not to administer life-sustaining treatment
    • Living wills are required to be in writing and signed by the client. The client’s signature must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the client is receiving care, from being a witness.
    • The living will is a witnessed document indicating the client’s desire to be allowed to die a natural death, rather than be kept alive by heroic life-sustaining measures.
    • a written document that identifies a person’s preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery.
    • Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness.
    • The living will applies to decisions that will be made after a terminally ill client is incompetent and has no reasonable possibility of recovery.
    • gives information about what the client wants if he is in a terminal or permanently unconscious state.
    • “initiate potentially life-prolonging treatment unless the client refuses.”- A living will doesn’t go into effect unless the client is unable to make his own decisions. The nurse should give all appropriate care while also maintaining the client’s right to refuse treatment.
  • health care power of attorney
    
    • names another person to act on the client’s behalf for medical decisions in the event that the client can’t act for himself.
    • Durable powers of attorney: appoints a person (health care proxy) chosen by the client to make health care decisions on the client’s behalf when the client can no longer make decisions.
    • A health care power of attorney, not an advance directive, gives others power to make decisions about a client’s medical care.
• The living will and health care power of attorney aren’t the same.
• A living trust, which concerns property ownership, wouldn’t address the client’s concerns.

Answer 5

advance directive

Question 6

The client usually has a restriction of food and fluids for 6 to 8 hours before surgery

Answer 6

preoperative

Question 7

• Having the client deep-breathe hourly (5-10 deep breaths every hour) is the most appropriate action for the assistant to take to help prevent pulmonary
• Peristalsis returns gradually, usually the second or third day after surgery. Bowel sounds will be absent until then. complications.
• When the client resumes a solid diet postoperatively, failure to pass stool within 48 hours may indicate constipation.
• Urinary control may not return for 6 to 8 hours after surgery owing to the effects of anesthesia and bladder manipulation during surgery. Urine retention is common; voiding a small amount of urine after surgery may be indicative of urine retention.
• If the client does not have a Foley catheter, the client is expected to void within 6 to 8 hours postoperatively depending on the type of anesthesia administered; ensure that the amount is at least 200 mL.
• report immediately: A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately.

Answer 7

postoperative

Question 8

• The tube is flushed with 30 to 50 mL of water or NS (depending on agency policy) to ensure that all medication has been instilled. The tube is then clamped for 30 to 60 minutes (depending on the medication and agency policy) to ensure it is absorbed (if the tube is not clamped and is reattached to suction then the medication will be aspirated out with the suction).
• Flush the tube with 30 to 50 mL of water or NS (depending on agency policy) before and after medication administration and before and after bolus feeding.
• Change the feeding container and tubing every 24 hours.
• 2. Do not hang more solution than required for a 4-hour period; this prevents bacterial growth.

Position the client in a high Fowler’s position; if comatose, place in high Fowler’s and on the right side.

• usually, if the residual is less than 100 mL, feeding is administered; large-volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration.
• Provides liquefied foods into the gastrointestinal tract via a tube
• Warm the feeding to room temperature to prevent diarrhea and cramps.
• 6. Administer the feeding at the prescribed rate or via gravity flow (intermittent bolus feedings) with a 50- to 60-mL syringe with the plunger removed.
• Gently flush with 30 to 50 mL of water or normal saline (depending on agency policy) with the irrigation syringe after the feeding.
• Flush the tube with 30 to 50 mL of water or NS (depending on agency policy) before and after medication administration and before and after bolus feeding.
• Do not allow the feeding bag to empty.

Answer 8

enteral tube feedings

Question 9

Never induce vomiting following ingestion of lye, household cleaners, grease, or petroleum products.

Answer 9

Poison

Question 10

1 fl oz = ? mL

1 T = ? mL or ? tsp

1 t or tsp = ? mL

1 C = ? fl oz

Answer 10

1 fl oz = 30 mL

1 T = 15 mL or 3 tsp

1 t or tsp = 5 mL

1 C = 8 fl oz

Question 11

provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus
Removes fluid and gas from the small intestine.

Answer 11

Miller-Abbott tube

Question 12

milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues

Answer 12

lead poisoning

Question 13

• The nurse should not administer more than 3 mL per intramuscular or 1 mL per subcutaneous injection site; larger volumes are difficult for an injection site to absorb
• are administered at an angle of 45 to 90 degrees, depending on the size of the client.
• Subcutaneous needles are typically 3/8 to 5/8 inches (0.95 to 1.6 cm) in length.
• The skin should be pinched up at the injection site to elevate the subcutaneous tissue.

Answer 13

subcutaneous injections

Question 14

• The nurse should not administer more than 3 mL per intramuscular or 1 mL per subcutaneous injection site; larger volumes are difficult for an injection site to absorb and, if prescribed, need to be verified.
• always means an injection route and parenteral medications are administered by intravenous, intramuscular, subcutaneous, or intradermal injection
• pain with infusion is a sign of Catheter position at the insertion site due to movement. The catheter pressing against the vein causes the pain. This would be a common result due to normal movement of the client throughout the day.
• To give a Z-track injection, a nurse measures the correct medication dose and then changes the needle on the syringe. Changing the needle decreases pain by eliminating any medication that may have been left on the needle and that could irritate the skin.

Answer 14

parenteral

Question 15

see flashcard hero

Answer 15

intramuscular injections

Question 16

• Deep breathing helps prevent microatelectasis and pneumonitis
• deep breathing helps force air and fluid out of the pleural space into the chest tubes.
• The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface.
• the primary reason for deep breathing is to expand alveoli and prevent atelectasis.
• Instruct the client that a sitting position gives the best lung expansion for coughing and deep-breathing exercises.
• Instruct the client to breathe deeply three times, inhaling through the nostrils and exhaling slowly through pursed lips.
• Instruct the client that the third breath should be held for 3 seconds; then the client should cough deeply three times.
• The client should perform this exercise every 1 to 2 hours.

Answer 16

Deep-Breathing and Coughing Exercises

Question 17

• A nurse is taking a client’s blood pressure and fails to recognize an auscultatory gap. What should the nurse do to avoid recording an erroneously low systolic blood pressure?
  
  • Inflate the cuff at least another 30 mm Hg after she can’t palpate the radial pulse.
• Explanation:
  
  • The nurse should wrap an appropriate-size cuff around the client’s upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can’t palpate or auscultate the pulse, then continue inflating until the pressure rises another 30 mm Hg.

Answer 17

blood pressure

Question 18

positions the patient left side-lying (Sim’s) with knee flexed. this position allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution

Answer 18

enema

Question 19

1. Client is alert and oriented.
2. Client has voided.
3. Client has no respiratory distress.
4. Client is able to ambulate, swallow, and cough.
5. Client has minimal pain.
6. Client is not vomiting.
7. Client has minimal, if any, bleeding from the incision site.
8. Client has a responsible adult available to drive the client home.
9. The surgeon has signed a release form.

Answer 19

general criteria for client discharge

Question 20

• Discharge teaching should be performed before the date of the scheduled procedure.
• Instruct the client not to drive, make important decisions, or sign any legal documents for 24 hours after receiving general anesthesia.
• sutures usually are removed in the physician’s office 7 to 10 days after surgery.
• staples are removed 7 to 14 days after surgery and that the skin may become slightly reddened when they are ready to be removed.
• avoid lifting for 6 weeks if a major surgical procedure was performed.
• Instruct the client with an abdominal incision not to lift anything weighing 10 pounds or more and not to engage in any activities that involve pushing or pulling.
• The client usually can return to work in 6 to 8 weeks depending on the procedure and as prescribed by the physician.

Answer 20

discharge teaching

Question 21

• each application should not exceed 20 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat
• increases circulation
• eases pain and edema

Answer 21

heat application

Question 22

• each application should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasodilation instead of vasoconstriction
• relieves pain but not edema
• limits swelling and bruising

Answer 22

Ice application

Question 23

• Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema.
• Edema, pain, and coolness at the site
• Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue.
• may or may not have a blood return
• is a form of tissue damage; it may also called extravasation.
• is seepage of the IV fluid out of the vein and into the surrounding interstitial spaces.
• occurs when an access device has become dislodged or perforates the wall of the vein or when venous backpressure occurs because of a clot or venospasm.
• Evaluate the IV site for infiltration by
  
  • occluding the vein proximal to the IV site.
    
    • If the IV fluid continues to flow, the cannula is probably outside the vein (infiltrated)
    • if the IV flow stops after occlusion of the vein, the IV device is still in the vein.
  • Lower the IV fluid container below the IV site, and monitor for the appearance of blood in the IV tubing; if blood appears, the IV device is most likely in the vein.
• If infiltration has occurred, remove the IV device immediately; elevate the extremity and apply compresses (warm or cool, depending on the IV solution that was infusing and the physician’s prescription) over the affected area.
• Do not rub an infiltrated area, which can cause hematoma.
• An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue.
• When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop.

Answer 23

infiltration

Question 24

refers to the differential between systolic and diastolic blood pressures.

Answer 24

pulse pressure

Question 25

The differential between the apical and radial pulse rates

Answer 25

pulse deficit

Question 26

are breaths that become progressively deeper followed by shallower respirations with apneic periods.

Answer 26

Cheyne-Stokes respirations

Question 27

• are rapid, deep breaths without pauses.
• abnormally deep, regular, and increased in rate.

Answer 27

Kussmaul’s respirations

Question 28

• receiving immunizations such as influenza, pneumonia, and shingles are necessary to prevent disease.
• refers to specific actions taken to optimize the health of the older individual by making the client more resistant to disease or to ensure that the **environment will be less harmful. **
• includes education programs that promote mental health and prevent future psychiatric episodes such as sexual education classes for adolescents.

Answer 28

primary prevention

Question 29

• diagnose and treat an existing disease in its early stages before it results in significant morbidity.
• Examples include public education to promote breast self-examination or screening programs for hypertension or diabetes.
• involves treatment to reduce psychiatric problems (for example, handling crisis intervention in an outpatient setting, administering and supervising medication regimens, and participating in the therapeutic milieu).

Answer 29

secondary prevention

Question 30

• involves treatments aimed to reduce the negative effects of established disease by restoring function and reducing disease-related complications.
• Examples include administration of medications to optimize therapeutic effects, moving and positioning to prevent complications of immobility, and assisting with passive and active range-of-motion exercises to prevent disability.
• Tertiary prevention involves helping clients who are recovering from psychiatric illness; activities directed toward providing aftercare and rehabilitation are part of this role.
• Conducting a postdischarge support group is a tertiary prevention activity.

Answer 30

tertiary prevention

Question 31

reduces the activity of the cilia lining the respiratory tract, increasing the client’s risk of ineffective airway clearance after surgery.

Answer 31

smoking

Question 32

• Drawing blood specimens from an extremity in which an intravenous solution is infusing can produce an inaccurate result.
• Prolonged use of a tourniquet and clenching and unclenching the hand before venous sampling can increase the blood level of potassium, producing an inaccurate result.

Answer 32

drawing blood

Question 33

• Steel needles or butterfly sets
  
  • The set is a wing-tip needle with a metal cannula, plastic or rubber wings, and a plastic catheter or hub.
  • The needle is 0.5 to 1.5 inches in length, with needle gauge sizes from 16 to 26.
  • Infiltration is more common with these devices.
  • The butterfly infusion set commonly is used in children and older clients, whose veins are likely to be small or fragile.
• Plastic cannulas
  
  • Plastic cannulas may be an over-the-needle device or an in-needle catheter and are used primarily for short-term therapy.
  • The over-the-needle device is preferred for rapid infusion and is more comfortable for the client.
  • The in-needle catheter can cause catheter embolism if the tip of the cannula breaks.

Answer 33

IV cannulas

Question 34

• large-diameter lumen needles or cannulas are used, such as a 14-, 16-, 18-, or 19-gauge
  
  • For rapid emergency fluid administration
  • blood products
  • anesthetics
• a 20- or 21-gauge lumen or cannula
  
  • For peripheral fat infusions (lipids)
• 22- or 24-gauge lumen or cannula
  
  • For standard IV fluid and clear liquid IV medications
• 24- to 25-gauge lumen or cannula
  
  • If the client has very small veins

Answer 34

IV gauges

Question 35

Shorter secondary tubing is used for piggyback solutions, connecting them to the injection sites nearest to the drip chamber

Answer 35

IV piggyback

Question 36

see flashcard hero

Answer 36

SELECTION OF A PERIPHERAL IV SITE

Question 37

• Change the venipuncture site every 48 to 72 hours
• Change the IV dressing every 72 hours, when the dressing is wet or contaminated
• Change the IV tubing every 24 to 72 hours
• Do not let an IV bag or bottle of solution hang for more than 24 hours to diminish the potential for bacterial contamination and possibly sepsis.
• Actions for Inserting a Peripheral Intravenous Line
  
  • prime the IV tubing to remove air from the system
  • The vein is stabilized to prevent its movement and the skin is punctured.
• Actions for Removing a Peripheral Intravenous Line
  
  • The nurse is careful to stabilize the catheter so that it is not pulled, resulting in vein trauma.

Answer 37

INITIATION AND ADMINISTRATION OF IV SOLUTIONS

Question 38

see flashcard hero

Answer 38

CENTRAL VENOUS CATHETERS

Question 39

• Tuberculin syringe
  
  • holds 1 mL
  • measures small or critical amounts of medication, such as allergen extract, vaccine, or a child’s medication.
  • Round small, critical amounts or children’s doses to hundredths and measure in the 1-mL tuberculin syringe
• Insulin syringe
  
  • The standard 100-unit insulin syringe
  • Insulin should not be measured in any other type of syringe.

Answer 39

syringes

Question 40

(Total Vol / min) x Drop Factor = Drops/min

Answer 40

Flow Rate Formula (Drops (gtt) per minute)

Question 41

• Top priority (emergent)
  
  • trauma,
  • chest pain,
  • severe respiratory distress or cardiac arrest,
  • limb amputation,
  • acute neurological deficits,
  • who have sustained chemical splashes to the eyes
• Intermediate priority (urgent)
  
  • simple fracture,
  • asthma without respiratory distress,
  • fever,
  • hypertension,
  • abdominal pain,
  • renal stone
  • absent bowel sounds
• Low priority (non urgent)
  
  • minor laceration,
  • sprain,
  • cold symptoms
  • clients scheduled for surgery the following day
• Case
  
  • Treat the 12-year-old with asthma first by initiating an albuterol treatment. This action is quick to initiate, and the child or parent can be instructed to hold the apparatus while you attend to other clients. The firefighter is in greater respiratory distress than the 12-year-old; however, managing a strong combative client is difficult and time consuming (i.e., the 12-year-old could die if you spend too much time trying to control the firefighter). Attend to the teenager with a crush injury next. Anxiety and tachycardia may be caused by pain or stress; however, the swelling suggests hemorrhage. Next attend to the woman with burns on the forearms by providing dressings and pain management. The child with burns over more than 70% of the anterior body should be given comfort measures; however, the prognosis is very poor. The prognosis for the client in cardiac arrest is also very poor, and the CPR efforts have been prolonged.

Answer 41

triage