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NCLEX > Reduction of Risk Potential > Flashcards

Reduction of Risk Potential Flashcards

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1
Q

chest physiotherapy contraindications

A 
hemodynamic isntability
increased intracranial pressure
rib fracture
vertebral fractures
iinstability and recent hemoptysis - couhging up blood from your lungs
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2
Q

chest physiotherapy nursing considerations

A

auscultate breath sounds prior to performing the procedure to determine baseline resp status

perform pain assessment
place client in proper position

administer prescribed bronchodilator before chest physiotherapy

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3
Q

abdominal breathing

A

positioned on their back with their knees bent and hands placed on abdomen to create resistance

breathe from abdomen while keeping chest still

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4
Q

incentive spirometry

A

sit up if possible
exhale fully
place mouthpiece in mouth
take long, slow deep breath, raising the ball as high as possible
hold breath for 2-4 seconds before slowly exhaling

evaluate clients technique and record volume of air inspired

perofmr 5-10 breaths.sessions
- one session every hour while awake

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5
Q

nasal cannula

A

23 - 42%

1-6 L/min

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6
Q

face mask

A

40 - 60%

6- 8 L/min

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7
Q

partial rebreather mask

A

50- 75%

8 - 11L/min

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8
Q

nonrebreather mask

A

80 - 100%

12 L/min

this with flowmeter set at 15 liters will provide the highest FiO2 available

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9
Q

venturi mask

A

most accurate

24-40%

4-8L/min

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10
Q

tracheostomy collar

A

30-100%

8-10 L/min

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11
Q

oxygen hood

A

30 - 100%

8-10 L/min

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12
Q

oxygen teaching

A

oxygen is combustible

should start at low rate of 2-3 liters/min

to avoid oxygen toxicity:
evaluate what evel of inspired oxygen is sufficient to maintain an acceptable oxygen saturation

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13
Q

mechanical ventilator

A

if an alarm sounds while caring for a client on ventilator:
1. assess the client FIRST

if alarm continues to sounds and client develops distress:

  1. disconnect client from ventilator
  2. use manual resuscitation (ambu bag) to ventilate client
  3. call for help immediately
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14
Q

tracheostomy care complications

A 
acute:
bleeding
infection
aspiration
air leak
subcutaneous emphysema
tube displacement

chronic:
altered body image
trachel necrosis
tracheal stenosis

fungal infections can develop under moist tracheostomy dressings

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15
Q

tracheostomy care

A

obturator should be available at ALL times

in acute care settings:
- care should be shared between the nurse and respiratory therapist

in the home setting:
- managed by client and family members or home health or visiting nurse

nursing considerations:
monitor stoma fro infection and excoration
perofrm trach care
make sure trach is secure but not too tight

place new, reaplcement trach kit at clients bedside

perform regular oral hygience

monitor resp status and SaO2
evaluate response to oxygen therapy
ensure nutritional needs are met

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16
Q

tracheostomy suctioning

A

when performing suctioning:
do NOT apply suction for longer than 10 seconds

hyperoxygenate prior to an immediate after suctioning
- BEFORE AND AFTER

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17
Q

what if chest tube water seal breaks

A

submerge in sterile water, or sterile saline

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18
Q

what if chest tube comes out

A

cover hole with gauzed hand
petroleum jelly or vaseline gauze dressing
3 sided sterile dressing
tape

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19
Q

what is chest tube bubbling

A

where:
water seal or suction control chamber

water seal:

intermittent: Good
continuous: BAD
- means that there is an air leak

suction control chamber:

intermittend: BAD
- means that the suction is not high enough
continuous: GOOD

notify the HCP if:

  • bubbling in the water seal chamber conitnuous or worsens
  • drainage from chest tube is greater than 100 ml/hr
  • if drainage becomes bright red or the amount suddenly increases

*DONT MILK CHEST TUBE

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20
Q

Risk factors for DVT/VTE

A 
reduced bloodflow
increased venous pressure
mechanical injury to vein
-peripherally inserted venous catheter
- IV drug use

increased blood vsicosity
acquired

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21
Q

nonpharmacologic interventions for VTE

A

early ambulation
prevention dehydration
smoking cessation

TED hose, compression stocking
intermittent or sequential compression devices
- only effective if applied correctly and when client wears them continuously
- should only be removed for bathing, skin inspection and ambulation

SCDs are contraindicated for clients with an existing DVT, but should be applied to the unaffected extremity

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22
Q

NG tube considerations

A

fasten the tube securely to the client, using an appropriate securement device

set the wall suction unti to the prescribed suction intensity

  • 40 -60
  • shoudl NOT go over 80

monitor the character and amount of aspirated GI contents

monitor the skin integrity around the tube and use protective padding under device

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23
Q

abdominal drains

A

Penrose drains
jackson pratt drain
t-tube

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24
Q

penrose drain

A

simplet latex drain that is freely laid inside the wound/surgical site

without sutures to hold it in place

drainage flow onto a auze dressing
open system

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25
Q

jackson pratt drainage and ahemovac

A

attached to a bulb-like (JP) or spring like (hemovac) container that applies suction when it is compressed

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26
Q

t-tube

A

placed in the comon bile duct of the gallbladder to allow for the passage of bile

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27
Q

abdominal drains nursing responsibilities

A

regular assessment/data collection
document color, consistency, and odor of the drainage
- with changes noted and reported to surgeon

monitoring the skin around the drain for damage and signs of infecting

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28
Q

types of enemas

A

oil retention
soapsuds
tap water

used to administer Kayexalate for treatment of hyperkalmiea

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29
Q

enema nursing considerations

A

should not administer if client had recent colon or rectal surgery, acute myocardial infarction or appendicitisw

should be used with caution for elderly clients because they are more at risk for hyperphosphatemia, perforation and sepsis

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30
Q

procedural sedation

A

also known as moderate or conscious sedation

common drugs for procedural sedation:
- benzodiazepines (midazolam, diazepam)
- fentanyl
- propofol
these are administered IV push

an RN may administer procedural sedation under a physicians supervision

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31
Q

nursing care procedural sedation

A

airway management
able to see life threatening dysrhythmias
ensure emergency resuscitation equipment
continuous ECg, capnography and pulse oximetry
drug reversal agents
-naloxone, fulmazenil

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32
Q

gauze

A 
advantages:
wicks away wound exudate
does not interact with wounds
comes in mayn sizes and lengths
supplied as a roll
disadvantages:
non adhesive
non-occlusive
fibers may shed or adhere to the wound
absorbs topically applied medications like ointment or cream
33
Q

dressings

A

premedicate the client with ana analgesic before a complex dressing change

if a drain is present, carefully remove wound dressing one layer at a time to avoid disloding the drain

FIRST post-operative dressing change is usually performed by the surgeon, not the nurse

34
Q

casts management

A

monitor neuro status
elevate affected extremity on several pillows

apply ice for 24 hours

never relieve itching by inserting something into the cast
immediately notify HCP if experiencing:
- foul odor
- drainage from a cast
- changes in integrtiy of the cast

reassess for numbness, pain, impaired circulation

a cast may smell “sour” but not “foul”

35
Q

traction management

A

bucks tractions, skeletal traction, cervical skeletal traction like a halo brace

  • screws are surgically inserted directly into the bone
  • allows for longer traction time and heavier weights

inspect traction equipment at least every 8-12 hours
weights should NOT be allowed to rest on the floor

implement pressure reduing measures
perform pin site care

notify HCP if severe pain from muscle spams

diligently monitor and treat clients pain

36
Q

hemorrhage postop care

A

monitor amount and character drainage

monitor signs of hypovolemia and hypovolemic shock

37
Q

atelectasis and penumonia post op care

A 
monitor signs of:
low O2
dyspnea
adventitious breath sounds
productive cough
fever
leukocytosis, tachyardia
38
Q

venous thrombembolism post op care

A

monitor signs of:
calf pain
swelling
suddent onset of shortness of breath as indicative of pulmonary embolism

39
Q

paralytic ileus post op

A

monitor for bowel sounds, abdominal distention and the passage of flatus or stool

40
Q

cardiac enzymes

A 
CK-MB
Troponin
C-reactive protein
Liquid Profile.Panel
BNP
41
Q

CK-MB

A

detected in the blood within 3-5 hours post MI

42
Q

Troponin

A

elevated 4-8 hours after heart attack

used to diagnose a heart attack and to assess the damage to the heart

43
Q

c-reactive protein

A

protein produced by the liver

levels rise with inflammaiton throughout the body

may help determine the risk of future cardiac events who had a heart attack

can get with simple blood draw

44
Q

liquid profile panel

A

should taking nothing but water by mouth 8-12 hours prior to blood draw

45
Q

BNP

A

helps diagnose and evaluate clients for heart failure

use for prognosis and to monitor therapy of clients with HF

normal range: <100

46
Q

angiogram cardiac catheterization

A

use to evaluate specific areas of the arterial system by injecting a dye through a catheter at the femoral or radial artery

dye makes coronary arteries visible on fluoroscopy

preoperatively:
evaluate history of allergy to iodine or radiopague dye
- if allergic, then premedicate for antihistamine

clients with impared renal functions are at an increased risk for futher renal damaged
- will receive large amounts of IV fluids to flush out the contast dye during procedure

acetylcysteine may be prescribed as a renal protectant

postoperatively:
clients who have catheter inserted in their groin will have a compression bandage on the insertion site
- must lie flat on their back for several hours post procedure

monitor catheter insertion site for bleeding or hematoma developmoent

distal pulses and vital signs are monitored for 7 hours:

  • 4 times in 15 minute intervals
  • 4 times in 30 minute intervals
  • 4 times in hourly intervals
47
Q

echocardiography

A

can be done at bedisde and performed by technician

used to evaluate structural defects and abnormalities of the heart valves, chambers and muscles

risk free and does not require specialized intervention before or after procedure

may be performed trans-esophgally TEE

48
Q

nursing consideration for TEE

A

maintain NPO status during prescribed hours before TEE
monitor return of gag reflex post procedure

monitor for resp depression due to procedural sedation
offer throat lozenges for residual throat discomfort

49
Q

cardiac stress test

A

clients walk on treadmill or ride stationary bicycle while connected to ECG monitoring

will exericse until predetermined heart rate is reached, 20 min have elapsed or if the clients starts to experience chest pain, fatigue, dyspnea, vertigo, or hypotension

50
Q

cardiac stress test management

A

ensure that client adhere to pre-procedure diet restrictions:
- avoiding caffeine or caffeinated beverages

making sure client remains NPO or only eats a light meal

wear comfortable clothing and footwear

51
Q

creatinine clearance

A

client eliminates in a 24 hour period

collection should be kept on ice during collection

52
Q

glomerular filtration rate

A

amount of urine produced by the kidney/min
normal: 90-120

describes the stages of chronic kidney disease:
stage 1: GFR greater than 90 mL/min

stage 2: GFR 60- 89 ml/min
- mild CKD

stage 3: 30-59 ml/min
- moderate CKD

stage 4: 15 - 29 ml/min
- severe CKD

stage 5: less than 15 ml/min
- end stage kidney disease

53
Q

cytoscopy

A

endoscopic procedure for direct visualization of the bladder and urethra

performed to dilate the urethra, place ureteral stents, resent and enlarged prostate gland

pre-procedure:
informed consent
completel bowel prep to empty the GI tract of any stool

ensure that client is NPO for prescribed time frame

post-procedure:
monitor character and volume of urine
check for abdominal distention, urinary frequency

urine is typically pink in color after the exam

if client expierneces worsening abdominal or pelvin pain post exam
- that can indicate urinary tract or bladder perforation

54
Q

intravenous pyelogram

A

provides x ray of kidneys, ureters and bladder

bowel preparation is required
night before test, client may be NPO after midnight

before procedure:
determine iodine sensitivity

during injection, it is normal for clients to experience burning in the vein or a salty taste in their mouth

x-rays are taken at intervals after dye is injected

55
Q

specimen collection

A

should go straight to the lab

do not allow specimen to sit at room temperature

56
Q

paracentesis

A

needle aspiration of fluid from abdominal cavity used for examination and treatment of ascites

can be done at bedisde
in semi-fowlers position

instruct client to empty bladder BEFORE procedure to decrease the risk of accidnetal puncture

post procedure:
monitor worsening abdominal pain
abdominal rigidity and rebound tenderness
- these can be indicative of peritonitis

57
Q

liver scan

A

evaluate size and shape of liver
radiopague dye is used during the exam

ask about previous allergies and previous iodine sensistivity
- must be monitored for anaphylaxis
those who are sensitive should use a aqueous of water based dye

will administer cleaning enema after the exam to remove barium and prevent impaction
x-rays may be repeated after all the barium has left the body

58
Q

amylase

A

help and diagnose acute chronic pancreatitis

client will restrict food for 1-2 hours before the test and avoid opiates for 2 hours before the test

normal value: 23-85

59
Q

ammonia

A

used to investigate changes in behavior and latered level of oconsciousness due to severe liver disease

use to support reye syndrome

refrain from smoking for several days prior to collection of sample

60
Q

sputum analysis

A

used to determine if abnomral lung cells are present
identify cause of pulmonary infection

should be encouraged to take fluids the night before the test
if possible, collection should take place in morning

prior to test, client should rinse their mouth with water
- dont brush teeth, eat or use mouthwash before the test

61
Q

acid fast bacillus smear and culture

A

used to dientify causative agent for TB

3 sputum samples are collected early in the morning on 3 different days

prior to test:
client can rinse their mouth with plain water, NOT mouthwash
difference between spit and sputum should be emphasized

sputum: mucus that you cough up from deep inside your lungs
spit: saliva

62
Q

mantoux test

A

readings are taken 48-72 hours after injection
-positive result is injection isred and swollen

false positive may result if people have receive BCG vaccine

63
Q

bronchoscopy

A

used to investigate source of bleeding in lungs, biopsy, remove secretion and foreign bodies

NPO at least 4 hours before the procedure and in most cases client will receive procedural sedation

may experience sore throat post test
remind client to sit or lie on their side
remain NPO until their gag reflex returns

64
Q

pulmonary function test

A

measures the lungs capacity to hold air, move air in and out

exchange oxygen and carbon dioxide

refrain from smoking for 4 hours prior to test

may also be asked to withhold bronchodilator until after test

65
Q

thoracentesis

A

fluid from pleural space is removed for diagnostic testing

will be asked to sit at the side of the bed and lean forward
local anestheticis used prior to needle insertion

may feel some pain as their lungs fill with air and expand against the chest wall
- may need to cough, feel light-headed and or short of breath during or after procedure

no more than 1,000mL should be removed at one time

monitor breath sound and vitals frequently
monitor for leakage of fluid at puncture site
- sterile dressing will be applied after the test and a chest X-ray may be ordered

66
Q

CT scan of the brain

A

if contrast dye is used with scan, informed consent must be obtained
-painless but client ust remain immbolie during exam
this can cause anxiety and may be challenging for clients with dementia, delirium, claustrophobia

if contrast dye is used
- may experience flushed, warm face and/or metallic taste during injection
assess for allergic response to dye like rash, itching, angioedema, uritcaria

after CT scan, encourage client to intake fluids to pee out the contrast

67
Q

MRI

A

must remove all metal

68
Q

PET scan

A

provides 2-3D dimensional pictures of the brain

used to diagnose stroke, brain tumor, epilepsy, parkinsons and head injuries

clients inhales or is injected with radioactive substance and then is scanned

must lie still while gamma rays are detecting the body tissues
- may experience dizziness and headaches, during and after the test

69
Q

lumbar puncture

A

appearance of CSF is normally colorless, clear and almost entirely free of colles
normal pressure: 50-180

70
Q

lumbar puncture nursing considerations

A

informed consent
position client on one side in a fetal position with knee close tot heir chest or leaning forward while sitting

local anesthetic will be injected
- will feel a stinging sensation and pressure as theh spinal needle is inserted

instruct clients to lie flat for severl hour afterward
drink additional fluids
administer analgesics as needed

apply sterile dressing to the site
perform neuro-sensory assessment every 15-30 min until pt is stable

71
Q

EEG

A

painless test that measures electricaly activity in the brain

can have bright or flashing light or noises

usually reclines in a chair or ona bed during the test and may take up to an hour
- if taken dring sleep, it can take around 3 hours

after test, nurse will remove electrode paste from scalp and hair

72
Q

bone scan

A

involves the use of a radionucleide administered through IV and creates an image

radioactive material poses no threat because is readily deteriorates in the body

taken to nuclear medicine department 4-6 hours after injection

  • procedure take around 30-60 in
  • patient must lie still for accurate test results

no special care is required
radioisotope is excreted in stool and urine, but no preautions are required in handling the excreta
- remin client to increase fluid intake

73
Q

DEXA scan

A

used to screen and diagnose osetoporosis

low dose X-rays are used to examine bone density at lower spine, hip and wrist

normal: <1 SD below normal
osetopenia: 1.0 - 2.5 SD below normal
osteoporosis: >2.5 SD below normal

74
Q

oral glucose tolerance test

A

diagnosis of diabetes mellitus

client must fast for 12 hours prior to the test

during test, blood samples are drawn at set intervals after client drinks liquid containined concentrated glucose

test can take up to 3 hours

glucose levels are taken 2 hours after drinking the glucose
levels that are greater than 200 means positive

75
Q

prostate specific antigen test

A

blood draw
should be done prior to digital rectal exam or biopsy
six weeks after manipulation of the prostate

76
Q

human chorionic gonadotropin

A

used to confirm or monitor pregnancy

no special preparation is needed

negative: <5
positive: >25

77
Q

colposcopy

A

recommended that client does not have vaginal intercourse, use tampons or take vaginal medications a day or 2 before the colposcopy

can use OTC analgesics prior to and after the procedure

78
Q

cervical biopsy

A

no anesthesia is needed
may feel a cramping sensation during or after the test

should wait 3 days to have intercourse, douche or go swimming

79
Q

breast biopsy

A

instruct to use OTC analgesics for post-procedural pain

  • acetaminophen
  • ibuprofen

NCLEX (21 decks)

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