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Elaina Nursing Practice 3 - test 3 > Scenario Test > Flashcards

Scenario Test Flashcards

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1
Q

Blood transfusions Signs & Symptoms

Circulatory Overload (7)

A 
Dyspnea	
Crackles at lung bases
Tachycardia
Hypertension
Cough
Increased venous pressure
Distended neck veins
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2
Q

Blood transfusions Signs & Symptoms

Acute Hemolytic Transfusion (13)

A

Acute Hemolytic Transfusion
Severe pain in chest and kidney area

Increased temp (up to 105) & heart rate

Chills, headache, nausea, dyspnea, anxiety

Pain & heat along vein receiving blood

Hypotension, low back pain, possibly death

Disseminated intravascular Coaugulation

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3
Q

Blood transfusions Signs & Symptoms

Allergic reaction (severe) (8)

A

coughing, nausea, vomiting, respiratory
distress, wheezing, hypotension, LOC,
cardiac arrest

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4
Q

Blood transfusions Signs & Symptoms (5)

Febrile non-hemolytic

A

Flushing, chills, headache, muscle pain

Fever greater than 1 degree above baseline

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5
Q

Blood transfusions Interventions

Circulatory Overload

A
  1. Stop or slow infusion as ordered
  2. Elevate patient’s head
  3. Notify health care provider
  4. Administer diuretics as ordered
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6
Q

Blood transfusions Interventions

Acute Hemolytic Transfusion

A
  1. Stop transfusion
  2. Remove blood product
  3. Maintain IV access
  4. Notify health care provider
  5. Monitor Vitals q 15min.
  6. Administer ordered therapy
  7. Insert foley
  8. Monitor in and out
  9. Assess for shock
  10. dialysis may be required
  11. obtain blood and urine sample
  12. Document
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7
Q

Blood transfusions Interventions

Allergic reaction (severe)

A
  1. This in a LIFE-THREATENING REACTION
  2. STOP TRANSFUSION
  3. maintain IV access
  4. Notify health care provider and blood bank
  5. Administer antihistamines, corticosteroids, epinephrine, and antipyretics as ordered
  6. measure and document vital signs until stable
  7. Initiate CPR if necessary
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8
Q

Blood transfusions Interventions

Febrile non-hemolytic

A
  1. Stop transfusion
  2. Administer antipyretics as ordered
  3. Monitor temperature q 4 hr.
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9
Q

Blood transfusions Onset

Circulatory Overload

A

Anytime during or within 1-2 hours

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10
Q

Blood transfusions Onset

Acute Hemolytic Transfusion

A

5-15 min.

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11
Q

Blood transfusions Onset:

Febrile non-hemolytic

A

30 from start of transfusion to 6hrs after

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12
Q

Blood transfusions Onset

Allergic reaction (severe)

A

5-15 min

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13
Q

IV Precautions

Because IV meds are immediately available to the bloodstream once administered:

CHECK FOR (6)

A
  • recommended dilutions and rate of admin
  • adverse reactions
  • for allergic reactions
  • phlebitis
  • speed shock
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14
Q

IV COMPLICATIONS

Systemic (4)

A

•Fluid overload/deficit

◦fluid overload
◾pulmonary edema (crackles)
◾peripheral edema

•Air embolism

◦sudden onset
◦SOB
◦chest pain

•Septicemia and other infection

◦fever

•Catheter damage/breakage (foreign body embolus)

◦check tip of IV catheter after removal
◦chart “catheter removed, tip intact)

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15
Q

IV COMPLICATIONS

Local (6)

A

•Infiltration and extravasation

◦extravasation
◾infiltration that causes cell death to surrounding tissue
◾eg. chemo

•Phlebitis
◦redness going up the vein

•Thrombophlebitis

◦dislodged clot

•Hematoma

◦bruising and accumulation underneath

  • Clotting and obstruction, precipitation, malposition
  • Dislodgement
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16
Q

IM volume for infants

A

0.5 ml

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17
Q

IM volume for Toddler

A

1-2 ml

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18
Q

IM volume for Preschool and older children:

A

2-3 ml

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19
Q

IM volume for Adolescent and adult

A

3-5 ml

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20
Q

Type of Injection

Intradermal (ID)

A

25-27 gauge
3/8 to 5/8 length
Volume 0.01-0.1
Sites forearm and upper back

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21
Q

Type of Injection

Subcutaneous (SC)

A

25-27 gauge and 26- 30 for peds
5/8 - 1” length
Volume 0.5 - 1 ml
Sites - outer aspects of arms, abdomen, anterior aspects of thigh

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22
Q

Type of Injection

Intramuscular (IM)

A

18 - 25 gauge
1/2 to 3” length
Volume 0.5-5

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23
Q

Recommendations for Mixing Insulins

A

Cloudy, clear, clear, cloudy
inject air into cloudy ( NPH - intermediate), inject air into clear (Toronto, Humulin, or Novolin -R) withdraw from clear, withdraw from cloudy

24
Q

IM deltoid injection land marking

A

Locate the Acromion Process and go three fingers below

25
Q

IM Ventrogluteal injection land marking

A

Locate the greater trochanter, place palm on trochanter, point thumb to groin, and index finger to the anterosuperior iliac spine, and middle finger to the iliac crest

26
Q

IM Vastus lateralis injection land marking

A

Locate the greater trochanter with one hand and the knee with the other. Anterior lateral aspect of thigh is the injection site

27
Q

Supplies for Wound Care

16 items

A

1.Sterile Gloves
2.blue pads
3.clean gloves
4.Cleaning solution (check expiration date)
5.Sterile dressing Tray
6.Sterile kidney basin
7.2-3 Abdominal Pads
8.4x4 and 2x2
9.packing
10.scissors
11.syringe
12.irrigation tip
13.Tape
14.measuring tape
15.pen & paper
16hand sanitizer

28
Q

Supplies for Catheter

10 items

A
  1. basin, soap
  2. wash cloth, towel
  3. catheter tray
  4. clean gloves x 2
  5. sterile gloves x 2
  6. blue pads
  7. catheter bag + tube
  8. hand sanitizer
  9. pad + pen
  10. tape
29
Q

Supplies for Ostomy

14 items

A
  1. stethoscope
  2. clean gloves
  3. basin
  4. facecloth
  5. towel
  6. measuring tool
  7. scissors
  8. barrier paste
  9. pouch and flange
  10. pouch closure clip
  11. ostomy belt ?
  12. adhesive remover
  13. skin barrier
  14. ostomy deordant
30
Q

Supplies for NG tubes

16 supplies

A
  1. NG tube
  2. water soluble jelly
  3. pH test strips
  4. tongue depressor
  5. flashlight
  6. emesis basin
  7. Tape or bone
  8. safety pin
  9. tube for suction to container
  10. glass of water with straw
  11. suction equipment
  12. clean gloves
  13. elastic
  14. measuring cup
  15. 60 cc catheter tip syringe
  16. connection two way tip
31
Q

what are the 6 rights?

A
  1. Patient
  2. Medication
  3. Dose
  4. . Time
  5. Route
  6. Documentation
32
Q

Oral suctioning for Infant to 1

A

60-80

33
Q

Oral suctioning for 2-5

A

80-100

34
Q

Oral suctioning for 6-12

A

100-120

35
Q

Oral suctioning for 13- adult

A

100-150

36
Q

Post Op Memo

A

09:30 hrs: Received client from recovery awake and oriented x 3 spheres. Vital signs within normal limits. Client rates pain as a 1/10. Abdominal dressing dry and intact. Jackson pratt in situ draining sanguineous fluid. NG tube in situ and draining small amount of yellowish drainage. Foley catheter in situ and draining clear yellow urine, 350 cc in drainage bag. IV infusing well at 125 cc/hr of NS, 650 TBA. IV site intact and patent. —————————————-MWalsh, RN

37
Q

Suture Removal Memo

A
  1. 21:00 hrs: 10 interrupted sutures removed as per orders. Incision cleansed with NS. No puffiness noted. Small reddened area at proximal end. 5 ½ inch steri-strips applied. Client tolerated well. —————————————M. Walsh, RN
38
Q

Discontinue Saline Lock memo

A
  1. 10:00 hrs: D/c’d saline lock as per doctor’s orders. Cannula tip remains intact. Pressure applied for 2 minutes. Insertion site cleansed. Band-Aid applied. Client tolerated procedure well. ——————————MWalsh, RN
39
Q

NG tube insertion Memo

A
  1. 09:45 hours: #16 F NG tube inserted in right nare for a small bowel obstruction. Prompt returns of brown fluid obtained. pH of gastric aspirate is 4. NG tube connected to intermittent low suction. Client tolerated procedure well. Client sent to x-rays for CXR.————–MWalsh, RN
40
Q

NG tube irrigation Memo

A
  1. 09:45 hours: Client c/o of abdominal distention and nausea. NG output decreased. NG tube irrigated with 50 ccs of NS. No resistance met. Obtained prompt returns of 60 ccs of brownish fluid. NG tube reconnected to intermittent low suction. Client tolerated procedure well. ————————-MWalsh, RN
41
Q

NG discontinue Memo

A
  1. 09:45 hours: #16 F NG tube discontinued from right nare as per doctor’s order. Catheter tip intact. 400 cc of dark green gastric content discarded. Cleansed client’s face, provided mouth care. Change in diet explained to client. Client tolerated procedure well. ———MWalsh, RN
42
Q

Chest tube Memo

A
  1. Chest tube remains in situ. Dressing dry and intact at insertion site. Chest tube draining 150 ml of sanguinous fluid in last hour, no clots present. Vital signs within normal parameters. Gentle bubbling present in the three-chamber water-seal system. Suction remains at -20 cm. Air entry remains decreased in left lower lobe. Client states no respiratory difficulty. Remains comfortable. ———————————–MWalsh, RN
43
Q

Stoma care memo

A
  1. 09:45: Removed the two-piece pouching system from the ileostomy for 100 ccs of brown semi-liquid content. End stoma remains brick red. Skin surrounding stoma is dry and intact. Area cleansed with warm tap water. New appliance measured and cut to fit stoma. New two-piece pouching system applied. Client tolerated procedure well. MWalsh, RN`
44
Q

Foley insertion Memo

A

16 French 2-way indwelling catheter inserted as per pre-op orders. 600ml of clear, pale urine obtained. Balloon inflated with 10cc of sterile water. Specimen sent to lab for a C&S. Catheter attached to drainage bag. Client tolerated procedure well. MWalsh, RN

45
Q

Foley Removal Memo

A 
#16 French 2-way catheter removed as per order. Specimen sent to lab for C&S. Discarded 
400cc of dark amber urine from drainage bag. Meatus intact. Pericare given. Client tolerated procedure well\_\_\_\_\_\_\_\_MWALSH, RN
46
Q

Post operative Leg exercises

A

Have client assume supine position and demonstrate passive ROM exercises
Rotate ankle 5 times
Alternate dorsiflexion and planter flexion of both feet
Have client flex and extend knees 5 times
Alternate leg raises 5 times
Q2h

47
Q

Repositioning Client

A

every 2 hours

48
Q

Incentive Spirometer

A

Semi fowlers or high fowlers
With mouth on mouthpiece, inhale and hold breath for as long as tolerated
repeat 10-20 times every hour

49
Q

Controlled coughing

A

2 slow, deep breaths, inhale through nose, and exhale through pursed lips
Inhale deeply the 3rd time and held breath for the count of 3. Fully cough 2 to 3 consecutive coughs without inhaling in between from belly
Splint if abdominal surgery

50
Q

Diaphragmatic Breathing

A

place hands on anterior rib cage
slow deep breaths for a count of 3 and exhale through pursed lips
repeat 3-5 times every hour while awake

51
Q

Insulin Admin sites

A

abdomen, arms, thighs, buttocks,

52
Q

Ear drops

A

Side lying 5-10 min

53
Q

Eye drops

A

Gentle Pressure 30 secs

54
Q

Run IV at

A

50ml/hr to keep vein open

55
Q

Women foley

A

12-14 French

2-3 inches add 1-2 once urine is out

56
Q

Men Foley

A

16-18 French

7-9 inches add 1-2 once urine is out

57
Q 
S
T
O
M
A
A 
S- set up equipment
T-take off equipment
O- observe stoma and skin
M- measure stoma
A- assemble & apply

Elaina Nursing Practice 3 - test 3 (4 decks)

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