Skills, Interventions, & Assessments

Question 1

airborne precautions

Answer 1

• measles, varicella, tuberculosis (pulmonary or laryngeal)
• private room
• masks for caregivers and visitors (N95 or HEPA respirator for TB)
• negative pressure airflow 6-12 exchanges per hour
• pt should wear mask outside room

Question 2

droplet precautions

Answer 2

• streptococcal pneumonia or pharyngitis, Haemophilu influenzae B, scarlet fever, rubella, mumps, pertussis, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague
• private or cohort room
• masks for caregivers and visitors
• pt should wear mask outside room

Question 3

contact precautions

Answer 3

• respiratory syncytial virus, shigella, infectious enteric diseases (C. diff), wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms
• private or cohort room
• gloves and gown for caregivers and visitors
• disposal of infectious dressing material in nonporous bag without touching outside of bag

Question 4

protective environment

Answer 4

• immunocompromised pts, allogenic hematopoietic stem cell transplant recipients
• private room
• positive pressure airflow, 12 or more exchanges per hour
• HEPA filtration for incoming air
• mask for pt when out of room

Question 5

Neurovascular Assessment

Answer 5

• Pain
• Parasthesia
• Pulse
• Pallor/Polar (temperature)
• Pressure/Swelling
• Paralysis/Loss of function

Question 6

intramuscular injection

adult

ventrogluteal, vastus lateralis

Answer 6

needle: 1-1.5 inch, 19-23 gauge
method: 90 degree, z-track skin

max amount: 3 mL

for irritating meds, oil-based solutions, aqueous suspensions

Question 7

subcutaneous injection

adult

Answer 7

needle: 0.5-5/8 inch, 25 gauge
method: 45-90 degrees, pinch skin

max amount: 1 mL

only non-irritating, water-soluble medications

Question 8

intramuscular injection

adult

deltoid

Answer 8

needle: 5/8-1.5 inch, 22-25 gauge
method: 90 degree, z-track skin

max amount: 1 mL

for irritating meds, oil-based solutions, aqueous suspensions

Question 9

intradermal injection

adult and pediatrics

Answer 9

needle: TB syringe, 3/8-5/8 inch, 25-27 gauge
method: skin taut, 5-15 degrees, bevel up

max amount: 0.01-0.1 mL

Question 10

intramuscular injection

infant (1-12 months)

Answer 10

site: vastus lateralis
needle: 5/8 - 1 inch, 23-25 gauge
method: 90 degrees

max amount: 0.5 mL

Question 11

intramuscular injection

newborn (1-28 days)

Answer 11

site: vastus lateralis
needle: 5/8 inch, 25 gauge
method: 90 degrees

max amount: 0.5 mL

Question 12

intramuscular injection

toddler (1-2 years)

vastus lateralis

Answer 12

needle: 5/8 - 1 inch; 23-25 gauge
method: 90 degrees

max amount: 1 mL

Question 13

intramuscular injection

school age child (3+)

vastus lateralis

Answer 13

needle: 5/8 - 1.5 inches; 22-25 gauge
method: 90 degrees

max amount: 2 mL

Question 14

intramuscular injection

teen

vastus lateralis

Answer 14

Needle: 5/8 - 1.5 inches; 22-25 gauge

method: 90 degrees

max amount: 2.5 mL

Question 15

intramuscular injection

toddlers (1-2 years)

deltoid

Answer 15

needle: 5/8 - 1 inch; 22-25 gauge
method: 90 degrees

max amount: 0.5 mL

Question 16

intramuscular injection

school age children and teens

Answer 16

needle: 5/8 - 1 inch; 22-25 gauge
method: 90 degrees

max amount: 1 mL

Question 17

subcutaneous injection

infant (1-12 months)

Answer 17

site: anterolateral thigh
needle: 5/8 inch; 23-25 gauge
method: pinch skin, 45-90 degrees

max amount: 1 mL

Question 18

subcutaneous injection

school age children and teens

Answer 18

site: anterolateral thigh or triceps
needle: 5/8 inch, 23-25 gauge
method: pinch skin, 45-90 degrees

max amount: 1 mL

Question 19

Pediatric Maintenance Fluid Requirements Per Day

Answer 19

up to 10 Kg → 100 mL/kg/day, plus

10.1-20 Kg → 50 mL/kg/day, plus

>20 Kg → 20 mL/kg/day

Question 20

pediatric replacement fluid protocol

Answer 20

20 mL/Kg of NS or LR infused rapidly as IV bolus

isotonic only