NURS 311 FINAL

Question 1

Speed Shock

Answer 1

A sudden, toxic, adverse physiological reaction to IV medication or drugs that are administered too quickly

Question 2

Symptoms of Speed Shock

Answer 2

Flushed face, headache, tight chest, irregular pulse, loss of consciousness, cardiac arrest

Question 3

Infiltration

Answer 3

IV fluids enter the surrounding space instead of staying in the vasculature

Question 4

Symptoms of Infiltration

Answer 4

Blanching, edema, coolness, pain, numbness

Question 5

Extravasation

Answer 5

When interstitial medication causes damage to the surrounding tissues

Question 6

Treatment of Extravasation

Answer 6

Stop IV infusion, elevate limb, notify MD

Question 7

Thromophlebitis

Answer 7

Inflammation of the vein

Question 8

Symptoms of Thrombophlebitis

Answer 8

Pain, edema, redness, warmth

Question 9

Pneumothorax

Answer 9

Accumulation of air in the pleural cavity

Question 10

Hemothorax

Answer 10

Accumulation of blood/fluid in pleural cavity

Question 11

Placement of Chest Tube with a pneumothorax

Answer 11

placed anteriorly through the 2nd ICS

Question 12

Placement of Chest Tube with a hemothorax

Answer 12

placed posteriorly through the 8th or 9th ICS

Question 13

Dry Suction Water Seal System

Answer 13

1 - Suction Regulation
2 - Water seal Chamber
3 - Air leak monitor
4 - Collection chamber
5 - Suction monitor bellows

Question 14

Nursing Care for Chest Tubes

Answer 14

• Ensure all connection is secured with waterproof tape or zip ties
• Chest tubes may be clamped to assess whether removal is possible
• Chest tubes may be clamped for < 1 minute (to change drainage unit, to locate an air leak, to assess bubbling and fluctuation of unclamped chest tube)

Question 15

Patient assessment of a chest tube

Answer 15

Inspection (general, distressed, calm, SOB, cyanotic)
Vitals
Resp and O2 (auscultation, LOC, ABGs, SpO2, mucous membranes, resp effort)
Pain
Chest tube insertion site (D&I, occlude if air leak, excessive bleeding)
Encourage DB&C, ambulation

Question 16

Complication r/t chest tubes

Answer 16

• chest tube placement
• infection at the insertion site
• pneumonia
• shoulder disuse

Question 17

Central Venous Access Devices

Answer 17

More permanent IV cath

Question 18

PICC

Answer 18

In basilic or cephalic vein into superior vena cava, securing device placed

Question 19

Risks of PICCs

Answer 19

Phlebitis after insertion, more susceptible to kinks and damage, venous spasms

Question 20

Pros of PICCs

Answer 20

Lower risk of infection and air embolism

Question 21

Nontunneled Central Venous Catheter

Answer 21

Inserted internal jugular or subclavian vein

Question 22

Risks of NCVC

Answer 22

Greater risk of complications at insertion, high risk of infection, not used outside of hospital

Question 23

Tunnelled Catheter

Answer 23

For long term use when PICC is not appropriate

Question 24

Implanted Port

Answer 24

silicone catheter attached to a metal or plastic reservoir (port) which has a self-sealing septum for needle access

Question 25

Nurse management of CVC

Answer 25

Manage and assess site
Dressing changes and line/cap management
Administer meds
Withdraw blood

Question 26

Site assessment of CVC

Answer 26

• Skin for redness, swelling, leakage, phlebitis
• infection
• security of dressing, sutures, or securing device
• damage to catheter or caps

Question 27

Withdrawing Blood from CVC

Answer 27

• order is required
• blood may be taken from any lumen (except TPN line)
• withdraw blood before drawing specimen
• IV infusions turned off 1-2mins before
• lumens flushed after sampling

Question 28

Removal of CVC or PICC

Answer 28

Check order, HH, remove dressings and sutures
Apply for 5 minutes and apply occlusive bandage

Question 29

CVC removal

Answer 29

Remove on exhale, lie flat for 30 mins

Question 30

PICC removal

Answer 30

Extend arm out at 90 degree angle and do not manipulate arm above site

Question 31

Complications of CVADs

Answer 31

Infection, air embolism, VTE, catheter occlusion, displacement of catheter, pneumo/hemothorax, phlebitis, extravasation

Question 32

Clinical Manifestations of Fractures

Answer 32

edema and swelling, pain and tenderness, muscle spasm, bone deformity, ecchymosis, loss of function, crepidation

Question 33

Bone Healing Steps

Answer 33

1 - bleeding at broken ends of the bone with hematoma formation
2 - organization of hematoma into fibrous network
3 - invasion of osteoblasts and deposition of calcium
4 - callus formation
5 - remodelling

Question 34

Nursing assessment of Fractures

Answer 34

History, physical assessment (S&S), neurovascular assessment, peripheral vascular assessment (color, temp, cap refill, peripheral pulses, edema), peripheral neurological assessment (sensation, motor function, pain), lab work (low HGB, increased WBC or ESR), diagnostic imaging, psychological assessment

Question 35

Nursing diagnoses for fractures

Answer 35

• Acute pain due to fracture, edema, spasm and soft-tissue damage
• decreased mobility r/t acute pain
• potential NV compromise r/t altered perfusion
• infection r/t altered tissue integrity

Question 36

Cast Care

Answer 36

Can cause neurovascular complications if too tight - frequent checks
Ice and elevation for 24-28hrs
Report breaks in cast

Question 37

Traction Care

Answer 37

Pull ends of bone apart and reduce spasms

Question 38

Compartment Syndrome

Answer 38

A condition in which increased pressure within a limited space compromises circulation, resulting in ischemia and necrosis of tissues

Question 39

6 P’s of Compartment Syndrome

Answer 39

1. Paresthesia
2. Pain
3. Pressure
4. Pallor
5. Paralysis
6. Pulselessness

Question 40

Compartment syndrome treatment

Answer 40

compare extremities, do not apply ice or elevate, remove/loosen bandage, reduce traction weight