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Semester One - Nursing 111 > Week Fourteen > Flashcards

Week Fourteen Flashcards

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1
Q

What is a contagion check?

A

Information that is gathered at the time of admission about the client’s immunization history, recent exposure to communicable diseases, history of communicable diseases, and current signs of any illness

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2
Q

What is the rationale of a contagion check?

A

identify possible sources of contagious diseases so measures can be taken to prevent its spread, identify children/adults who require recommended immunizations

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3
Q

What are reasons for a transfer?

A

condition changing, treatments, need to go to a different floor or facility

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4
Q

Define Risk for Latex Allergy Response

A

At risk for allergic response to natural rubber latex products

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5
Q

Risks factors for Risk for Latex Allergy Response

A

children with three or more surgeries, professions with daily exposures to latex, hairdressers, janitors, allergies to bananas, apples, carrots, history or asthma, history of allergies

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6
Q

AMA Discharge

A

Against Medical Advice. Attempt to determine why client wants to leave, notify nursing supervisor and client’s MD, client signs appropriate forms (if they won’t sign, document and have witness), assist client to get ready and escort them to the door

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7
Q

What will the RN teach the client during the admission process?

A

facility processes/healthcare team members, condition or medication management, NUR care plan, possible discharge scenarios

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8
Q

Why should the RN pay attention to the client condition prior to initiating any admission procedures?

A

address basic needs according to maslow, establish nurse-client relationship, modifications, wellness, age, culture, database

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9
Q

What client information should be obtained during the admission process?

A

biographical data, chief complaint, history of present illness, past medical history, past surgical history, allergies, immunizations, medications, family history, support system, physical assessment, functional abilities, discharge needs

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10
Q

What does the RN need to do to complete the admission process?

A

orient client to routines and environment, client teaching, discharge planning, collect ordered specimens, initiate nursing care plan and nursing process, document and report

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11
Q

What is the RN’s responsibility in the transfer of a client?

A

facilitating interdisciplinary collaboration and ongoing communication, being a client advocate, identify and help the client to access resources necessary to support recovery or maintain health, reduce client and family stress by teaching them what to expect

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12
Q

Transferring within an agency

A

explain reason for transfer, don’t forget to transfer belongings, send original chart, make transportation arrangements

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13
Q

Transferring outside of agency

A

pack all belongings, send copy of chart, report

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14
Q

Receiving a transfer within an agency

A

obtain report, may need orientation to new unit, review chart, document time of arrival and condition of client

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15
Q

Receiving a transfer from outside agency

A

implement usual admission procedure, review information sent with the client

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16
Q

Receiving telephone report

A

document date/time of call, document name and credentials of caller, accurately document information reported, sign note with name and title, if you are receiving report, repeat the information back to send to ensure clarity

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17
Q

Giving telephone report

A

be concise and accurate with report, begin with name, title and relationship to client, include client name and medical diagnosis, report changes in nursing assessment, report current VS and baseline VS, report significant lab values, report TNI and client response, after giving telephone report, document date, time, and content of call, signature and title

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18
Q

When does discharge planning begin?

A

on admission

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19
Q

What is continuity of care?

A

the coordination of health care services by healthcare providers for clients moving from one healthcare setting to another and between and among healthcare professionals

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20
Q

What is the RN’s role in the continuity of care

A

initiate discharge planning upon admission, involve client and family or support persons, collaborate with healthcare professionals

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21
Q

What are the essential components of discharge planning?

A

review why client was admitted, maintain ongoing assessment of client, assess client and caregiver needs at time of discharge, determine interdisciplinary needs, encourage client and support person participation, review discharge teaching with client and/or support person, written discharge instructions given to client and/or support person

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22
Q

What should discharge instructions include?

A

list of all medications to be taken, treatments/procedures, dietary and activity order, health promotion strategies, referrals, when to call MD and proper phone number, follow-up appointment and dates

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23
Q

What should the RN’s checklist or discharge summary include?

A

description of client’s physical, mental, and emotional status, resolved health problems, unresolved or continuing health problems and needs, treatments to continue, medications, restrictions, functional abilities, comfort level, support networks, client education provided at time or discharge, discharge destination and who accompanied client, referral services, follow-up

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24
Q

Intravenous Therapy

A

Method of supplying fluids and electrolytes directly into the intravascular fluid compartment

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25
Q

How does IV therapy work?

A

A needle attached to a catheter of a specific gauge is inserted into a vein. The vein can be peripheral or central. The needle is removed and the catheter is attached to plastic tubing. The plastic tubing is attached to fluid and infuses based on the rate set by the provider.

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26
Q

What is an example of a peripheral vein?

A

antecubital

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27
Q

What is an example of a central vein?

A

jugular

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28
Q

What are 5 purposes for IV therapy?

A

Maintenance therapy for daily body fluid requirements, replacement therapy (fluids, electrolytes, blood, restoration therapy for loss due to decreased nutrition, route for IV drug administration, rapid access to circulatory system

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29
Q

What are the factors that influence the rate of flow of a gravity IV infusion?

A

gravity, pressure, space, viscosity

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30
Q

Gravity

A

Fluid flows from a higher area to a lower area

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31
Q

Pressure

A

Fluid flows from higher to lower pressure. Smaller gauge = more pressure

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32
Q

Space

A

Fluid can flow more quickly in a wide space

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33
Q

Viscosity

A

Fluids that are less vicious will flow more quickly

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34
Q

Intracellular Fluid

A

The fluid within the cells of the body. Present in cells through diffusion/osmosis across cell membrane

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35
Q

Extracellular fluid

A

Intravascular = fluid component in blood vessels. Extravascular = interstitial and transcellular fluid

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36
Q

Osmosis

A

Movement of water from an area with more water to an area with less water

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37
Q

Diffusion

A

Movement of solutes from an area of high concentration to an area of low concentration

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38
Q

Osmolarity

A

Concentration of solutes in a liter of solution

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39
Q

Tonicity

A

How the osmolarity will effect osmosis or diffusion on each side of the blood vessel membrane

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40
Q

Isotonic Solution

A

Same osmolarity as that of body fluids, no difference in concentration of solute between plasma and cells, fluid remains in the intravascular space, used to expand the intravascular compartment ** solution is the same as what is going on in the vein **

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41
Q

When would an isotonic solution be used?

A

surgery, or any time homeostasis should be maintained

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42
Q

What would you expect to happy if an IV has an isotonic solution?

A

nothing but maintenance. The solution is the same as what is going on in the vein so it will stay in the intravascular space

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43
Q

Hypotonic Solution

A

less solute in plasma than the intracellular fluid, plasma fluid level is greater than cells, fluid moves into the cells, used to treat cellular dehydration ** Moves fluid out of the intravascular space **

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44
Q

Is there more solute in the plasma or intracellular fluid?

A

The intracellular fluid

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45
Q

What would you expect to happen if an IV has a hypotonic solution?

A

The fluid will move out of the intravascular space and to the cells

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46
Q

When would a hypotonic solution be used?

A

To treat cellular dehydration

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47
Q

Hypertonic Solution

A

more solute in plasma than the intracellular fluid, plasma fluid level is less than cells, fluid move out of the cells to plasma

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48
Q

When would a hypertonic solution be used?

A

to decreased edema, expand blood volume, in instances of BP drop or blood loss

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49
Q

What would you expect to happen if an IV has a hypertonic solution?

A

IV fluid has more solute than the blood plasma, therefore the cells fluid will follow the solute and move out of the cells and into the vein

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50
Q

NS

A

normal saline 0.9%

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51
Q

DSW

A

5% dextrose in water

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52
Q

LR

A

lactated ringers

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53
Q

Lactated Ringers

A

A solution of several electrolytes, may be combined with either DSW or NS

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54
Q

How many grams of glucose and number of calories in one liter of D5W?

A

170 calories in 1 liter (17 calories in 100mL)

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55
Q

Dextrose is

A

glucose

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56
Q

1/2 NS

A

0.45% NaCl

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57
Q

Normal Saline is

A

NaCl

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58
Q

D5W

A

Isotonic

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59
Q

LR

A

Isotonic

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60
Q

NS

A

Isotonic

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61
Q

1/2NS

A

Hypotonic

62
Q

LR Na+

A

130 mEq

63
Q

LR Cl-

A

109mEq

64
Q

NS Na+

A

154 mEq

65
Q

NS Cl-

A

154 mEq

66
Q

1/2NS Na +

A

77 mEq

67
Q

1/2NS Cl-

A

77 mEq

68
Q

Infiltration

A

Inadvertent administration of a non-vesicant solution into the surrounding tissues

69
Q

Assessing Infiltration

A

swelling/blanching at site, decreased IV flow, pain

70
Q

Phlebitis

A

Inflammation of vein, increased risk for bloodstream infection

71
Q

Assessing Phlebitis

A

pain/warmth at site, linear pattern redness

72
Q

Non-Vesicant

A

not going to cause tissue damage

73
Q

Assessing Infection

A

drainage from IV site, warmth and redness of IV site, fever

74
Q

Circulatory Overload

A

Fluids administered faster than circulatory system can transport, filter, and excrete

75
Q

Assessing Circulatory Overload

A

peripheral edema, jugular vein distention, dyspnea, lung crackles, increased HR, elevated BP

76
Q

What should a nurse assess about the IV solution?

A

correct solution, correct flow rate, date and time hung, patency of tubing (kinked?)

77
Q

What should a nurse assess about the IV insertion site?

A

infection, infiltration, phlebitis, bleeding

78
Q

What other things should a nurse do about IV therapy?

A

monitor lab values

79
Q

Setting up or changing IV fluid/tubing

A

aseptic technique, maintain closed system - keep air out!

80
Q

Patient Teaching IV

A

purpose of IV therapy, care for site/equipment, abnormalities to watch for, when to report them, and to whom

81
Q

Interventions for Infiltration

A

change IV site, apply warm compresses

82
Q

Interventions for Phlebitis

A

change IV site, apply warm compresses

83
Q

Interventions for Infection

A

change IV site, culture the IV site (MD order), antibiotics (MD order)

84
Q

Interventions for Circulatory Overload

A

Decrease IV rate “KVO,” interventions to improve oxygenation, anticipate an order for diuretics, and other interventions for fluid volume excess

85
Q

What are common medications that can be given by IV infusion?

A

insulin, heparin, opioids, injectable potassium concentrates, neuromuscular blocking agents, chemotherapy drugs, oxytocic medications

86
Q

Medications administered IV are deemed what?

A

High Alert

87
Q

Best practices for medications administered IV

A

infuse only on an electronic infusion device, monitor blood levels of the medication, monitor specific lab values, monitor medications effects (intended and non-intended)

88
Q

What lab values are important with Heparin administration IV?

A

clotting values

89
Q

What lab values are important with insulin administration IV?

A

blood glucose

90
Q

Nursing Responsibilities for Potassium infusion

A

dilute in an IV solution, never given with a syringe directly into a vein, mix throughly when adding to an IV bag, infuse and less than or equal to 10 mEq per hour through a peripheral IV, max dose is less than or equal to 60 mEq/L, monitor carefully for infiltration, monitor serum K+ levels, never add to an existing IV infusion

91
Q

What is normal serum K+ levels

A

3.5-5.0 mL

92
Q

What is the max does for potassium infusion

A

60 mEq/L

93
Q

Documentation of IV therapy

A

site, client response to therapy, adverse reaction, type of fluid infusing with additives, flow rate in mL/hr, amount administered over a specific time period, type of infusion device

94
Q

D5 1/4NS

A

Isotonic

95
Q

D5LR

A

Hypertonic

96
Q

D5 1/2NS

A

Hypertonic

97
Q

D5NS

A

Hypertonic

98
Q

Grams of dextrose/100mL in D5 1/4NS

A

5

99
Q

Grams of dextrose/100mL in D5LR

A

5

100
Q

Grams of dextrose/100mL in D5 1/2NS

A

5

101
Q

Grams of dextrose/100mL in D5NS

A

5

102
Q

Na + in D5 1/4 NS

A

34 mEq

103
Q

Na + in D5LR

A

130 mEq

104
Q

Na + in D5 1/2 NS

A

77 mEq

105
Q

Na + in D5NS

A

154 mEq

106
Q

Cl- in D5 1/4NS

A

34 mEq

107
Q

Cl- in D5LR

A

109 mEq

108
Q

Cl- in D5 1/2NS

A

77 mEq

109
Q

Cl- in D5NS

A

154 mEq

110
Q

How much fluid is in the body of a premature infant?

A

90%

111
Q

How much fluid is in the body of an infant?

A

70-80%

112
Q

Why are infants at increased risk for fluid overload and deficit?

A

A decreased ability to regulate their intake and output and small body mass

113
Q

What IV equipment would you need for a pediatric client?

A

smaller gauge needle, sites different from adult: scalp veins, legs, insert IV in separate room from child’s “bedroom,” may use topical anesthetic, restraints, rubber band as tourniquet, never insist on parent assisting with restraining child, specialized devices for stabilizing site and preventing accidental dislodgment, use pump to regulate flow (very small amount of fluid are necessary compared to an adult)

114
Q

Interventions for IV therapy Infant

A

explain IV to parents, encourage tactile and verbal soothing, minimize parental separation

115
Q

Interventions of IV therapy Toddler

A

allow to express feelings, allow for mobility, encourage favorite toy/blanket for comfort, explain only shortly before procedure to child, minimize parental separation

116
Q

Interventions of IV therapy Preschooler

A

encourage to express/play out feelings, encourage mobility, explain in simple terms, use doll to demonstrate, explain that procedure is not punishment but to make them healthy, prepare just before procedure, praise cooperation and provide rewards

117
Q

Interventions of IV therapy School Age

A

encourage to express feelings, prepare in advance, explain in simple terms, involve child in procedure (tearing tape, holding tubing), diversional activities, peer contacts, give immediate praise for cooperation

118
Q

Interventions of IV therapy Adolescent

A

explain procedure in advance using adult terms, give choices in site selection, privacy, encourage participation in self care, allow to express feelings, use coping and relaxation techniques

119
Q

What happens to the blood vessels with age?

A

they become non-elastic

120
Q

Total body fluids for an elderly client

A

45-50%

121
Q

Why are elderly patients more at risk for fluid volume deficit and excess?

A

poor regulating systems, slower response to changes

122
Q

IV equipment and needs for IV therapy elderly patient

A

veins are fragile and roll easily, may have had many previous venipunctures, skin is very thin and SC tissue is diminished, loss of elasticity of blood vessels and dermis, apply warm compress to area to help distend vein to improve success, BP cuff may be used to distend vein, if use tourniquet apply over sleeve to prevent bruising, generally smaller gauge cannula, use a pump for more accurate control of flow rate, areas for IV access should have adequate tissue and skeletal support, therefore hand veins may not be the best choice

123
Q

Psychologic Support for IV Therapy Elderly

A

speak slowly, clearly, and directly to elderly patients with sensory deficits, address the patient by his or her proper name, explain the steps of the procedure to increase cooperation and decrease anxiety, do not use unfamiliar terminology, because of decreased dexterity, observe the elderly client who is to self administer infusion therapy to be sure they are proficient with all equipment

124
Q

KVO

A

Keep Vein Open

125
Q

Keep Vein Open

A

Very sow flow rate which must maintain IV site by preventing blood from clotting in the vein

126
Q

Drop Factor

A

Number of drops in 1 mL delivered by tubing. Found on tubing package.

127
Q

Mini/Micro Drop Tubing

A

60gtts/1 mL

128
Q

Intermittent Infusion Device (Saline Lock)

A

Clamped IV used for intermittent for medication

129
Q

Symptoms of circulatory overload

A

dyspnea, SOB, elevated blood pressure, dilated neck veins

130
Q

What is a normal KVO rate?

A

30-50mL/hour

131
Q

What is credit?

A

what is left in the bag

132
Q

What is the IV fluid intake?

A

What the client has taken in, the empty portion of the bag, what is gone

133
Q

Types of scalp vein needles

A

butterfly and wing tip needle

134
Q

Advantages of Scalp Vein Needles

A

good for one time short-term therapy, sides (wings) allow for easy insertion and taping

135
Q

Disadvantages of Scalp Vein Needles

A

Non flexible needle increases the risk of infiltration, could puncture self after discontinuing clients IV with contaminated needle

136
Q

Uses of Scalp Vein Needles

A

infants/children, adults with small veins, those receiving short-term therapy

137
Q

What are Scalp Vein needles made out of?

A

Stainless steel

138
Q

What lengths do scalp vein needles come in?

A

1/2 to 1 and 1/4 inch

139
Q

What is an over the needle catheter?

A

consists of a needle covered with a flexible catheter sheath. The point of the needle extends beyond the tip of the catheter. After the vein is punctured the needle is withdrawn and discarded leaving the flexible catheter in the vein.

140
Q

Over the needle catheter length

A

3/4 to 2 inches long

141
Q

Gauge of over the needle catheter

A

12-24

142
Q

Another name for an over the needle catheter

A

angiocatheter

143
Q

Advantages to angiocatheter

A

easy to insert, stable, allows for great patient mobility, patent longer, radiopaque (can see on x-ray), infiltration rate decreased

144
Q

Disadvantages to angiocatheter

A

sometimes difficult to secure with tape, increased risk of phlebitis

145
Q

Use of angiocatheter

A

long-term therapy, delivery of viscous fluids (blood hyperalimentation

146
Q

Drop Factor

A

permits a predictable amount of fluid to be delivered, drops per milliliter

147
Q

micro drop

A

usually required if the fluid is to be aministered at a rate of 50-70 mL/hour. delivers 60 drops/mL of solution

148
Q

macro drip

A

delivers 10-15-20 drops per mL of solution. should be selected with large quantities of solution or fast rates are required

149
Q

Intermittent infusion device

A

can be attached to an existing IV catheter to keep venous access available for admin of intermittent or emergency med when a continuous infusion is not required. hep or saline is usually injected periodically to keep blood from coagulating within the tubing

150
Q

intake

A

what went in patient

151
Q

credit

A

what is left in the bag

152
Q

What portions of the tubing and container (IV) must be kept sterile?

A

spike, inside of tubing, cannula end of tubing, spike port on IV bag, IV solution

Semester One - Nursing 111 (15 decks)

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