UAB 321L Skills Final Exam Graded A

TPN used for people who can't feed normally - ANSWER Crohns GI cancer Ileus Obstruction Vomiting TPN used when food isn't being absorbed right - ANSWER Burns Multiple injuries Radiation/chemo Ulcerative colitis ...

TPN used for people who can't feed normally - ANSWER Crohns GI cancer Ileus Obstruction Vomiting TPN used when food isn't being absorbed right - ANSWER Burns Multiple injuries Radiation/chemo Ulcerative colitis Short bowel syndrome TPN used to rest the bowel - ANSWER Post-op for GI surgery Chronic inflammatory diseases Diarrhea Sugar found in TPN - ANSWER Dextrose Monitor patient on TPN for - ANSWER Blood glucose- during (hyper), after (hypo)-decrease slowly Infection D/c can take up to 48 hours Use what technique when handling TPN and equipment for it - ANSWER Surgical asepsis Types of skin traction - ANSWER Bucks Pelvic Cervical What is bryant's traction? - ANSWER Used for kids less than 35 pounds with femoral shaft fractures Buck's skin traction is applied to BOTH legs How long can skeletal traction be used - ANSWER 4 months Make sure ends of exposed pins or wires are covered in - ANSWER Cork Skeletal traction-prevent injury to patient What should assess in skeletal traction? - ANSWER Neurovascular checks Skin checks VS q4 Pin sites and surrounding skin for infectious signs If your patient wants to ambulate, you can interrupt skeletal traction - ANSWER False Don't remove without orders Prevent footdrop and contractures for patients in what type of traction? - ANSWER Skeletal A client on skeletal traction complains of 6/10 pain at the site of insertion - ANSWER Assess deeper Shouldn't cause pain What types of exercises can skeletal traction patients do - ANSWER Isometric You must turn a patient on skeletal traction every hour to avoid complications - ANSWER False!! Must have order to turn Maintaining perfusion in skeletal traction - ANSWER Neurovascular checks Elevate extremity Fully assess complaint of pain before giving meds Assess CMS Assess in traction - ANSWER Pallor Blanching-nailbeds Pulse Temp Sensation to each digit (paresthesia test) Move digits freely (paralysis test) Best form of cervical traction - ANSWER Halo Allows more mobility Halo interventions - ANSWER CORRECT allen wrench taped to vest at all times AVOID UNSTRAPPING UNLESS RESCUING Staff RNs don't replace the liner inside- must be specially trained/orthotics Notify MD to consult orthotics to get a new liner Patients with external fixation are at high risk for - ANSWER Infection Provide good pin-site care Assess for infection When providing pin-site care - ANSWER Use a new cotton applicator for each site Perform daily/weekly after first 2-3 days Penrose drain - ANSWER Passive Soft and flexible-no collection device Sterile, large pin is put over the end to keep the tube from slipping into the skin all the way RBC transfusion - ANSWER Acute hemorrhage Low h/h Symptomatic anemia FFP transfusion - ANSWER Deficit of coagulation factors Bleeding/ need to undergo procedure Type and screen - ANSWER ABO typing Shows unexpected antibodies Type and cross - ANSWER Compatibility b/w donor and receiver blood ONLY DONE WITH PRBCs 2 nurses must check blood products - ANSWER True One unit of whole blood is - ANSWER 500mL One unit of PRBCs is - ANSWER 200-250mL Y-sets are used to - ANSWER Keep vein open while starting blood transfusion and to flush the line with NS before blood Patient concerning complaints after transfusion - ANSWER Chills/ fever greater than 1 degree Low back pain Increased RR/pulse Decreased BP Itching SOB Crackles Distended neck veins Cough Heparin and insulin - ANSWER High risk Titrating standards MUST BE ON IV PUMP Requires loading dose and continuous infusion Before starting/changing rate on a heparin/insulin infusion - ANSWER 2 nurses confirm patient identity and drug Rate- verify rate and time Change label must be placed in chart Consider before choosing Iv insertion site - ANSWER Age Length of time med will run Condition of vein Type of med/fluids Subsequent IV starts should be where in relation to the last site? - ANSWER Proximal Best to use which arm - ANSWER Non-dominant Peripheral short catheters are used for - ANSWER Peripheral veins Less than 1 week Angiocatheters - ANSWER Plastic cath fits over needle Butterfly - ANSWER Wing tipped PICC - ANSWER peripherally inserted central catheter Just above/below AC of RIGHT ARM Tip rests in superior vena cava Long term CVL - ANSWER Long term implantation Chronic illness- cancer treatment, TPN, frequent blood draws How do you choose a vascular access device? - ANSWER Patient preference Prescribed therapy- TPN/ chemo in central lines only Length of therapy- long term will need PICC or CVL Vascular integrity Before starting IV, assess - ANSWER Latex, tape, med, iodine allergies Vitals for baseline Bleeding issues Disease/injury to extremity Vein status To monitor an IV site - ANSWER Hand hygiene Inspect and palpate AT LEAST EVERY 8 HOURS Redness, warmth, bleeding, swelling, burning pain along vein Infiltration - ANSWER Fluid moves into tissue surrounding IV cath Coolness, blanching, tightness, edema, leakage, swelling STOP INFUSION AND REMOVE CATH Elevate extremity and apply heat to site to promote vasodilation and absorption of the fluid Extravasation - ANSWER Infiltration of a vesicant Tissue injury Burning, redness, blistering, ulceration STOP INFUSION, ASPIRATE REMAINING FLUID Remove cath Assess site for injury Apply new dressing Call provider Apply pressure to area of extravasation - ANSWER False Phlebitis - ANSWER Inflammation of the vein Mechanical from IV start Chemical from solution Bacterial from infection Redness, warmth, swelling, high temp Patient's IV site is tight, blanching, leaking - ANSWER Infiltration Stop infusion Remove catheter Apply heat Patient's IV site is blistering and patient complains of burning pain - ANSWER Extravasation Stop infusion Aspirate remaining fluid Remove cath Apply new dressing Call doc D/c for an IV - ANSWER Inspect D/c fluids first Remove cath Ensure it's in one piece Apply pressure and clean Dress Reasons to irrigate bladder - ANSWER Acute urinary retention Bladder spasm To free a blockage from catheter Removes pus and blood clots Provides meds Must have what to irrigate bladder? - ANSWER Order Open (manual) bladder irrigation - ANSWER Used for less frequent use Used when there are no blood clots or large mucous fragments Catheter is disconnected from drainage every time Closed bladder irrigation - ANSWER Instills sterile irrigant into the bladder allowing fluid to drain out Open irrigation used for - ANSWER Restoring patency of catheter Double lumen catheter Closed method is - ANSWER Preferred Reduced infection risk Closed irrigation details - ANSWER Can be intermittent or continuous Used after surgery to prevent blood clot catheter occlusion Triple lumen cath- drainage bag, solution, and balloon Solution flows in and comes out into collection bag Where should you put the bag of irrigant? - ANSWER On a IV pole Flow of irrigation is determined by - ANSWER Orders Assess outflow from urinary irrigation for - ANSWER Clots Changes in appearance Condom cath - ANSWER Flexible sheath rolled around penis Bag attached to adhesive backing to skin around genitals Non-invasive Straight catheter - ANSWER Inserted into bladder to empty it Can't be left in place Retention catheter - ANSWER Left in place over a period of time Suprapubic catheter - ANSWER Long term continuous drainage Diverts urine from urethra if injury, prostatic obstruction, stricture, or abdominal surgery has compromised urethral urine flow Max amount of O2 from nasal cannula - ANSWER 6L Simple mask is - ANSWER Non-rebreather with removed bag Water bottles are not used with - ANSWER Simple mask, non-rebreathers, venturi Never go below 5L of O2 per minute for which device? - ANSWER Simple mask Venturi mask - ANSWER Pieces for delivering specific oxygen levels as ordered Non-rebreather can deliver - ANSWER 60-80% oxygen Set to minimum of 10L Can go up to 15L Non-rebreather: if bag is collapsing with each inspiration - ANSWER Increase flow rate Never titrate NRB below - ANSWER 10L Partial rebreather can deliver - ANSWER 40-70% O2 Run at 10L If bag is collapsing, increase rate HOB in NG insertion - ANSWER 90 degrees Before inserting NG, assess - ANSWER Nare patency and skin integrity Measure NG - ANSWER Nose to earlobe to xiphoid process Mark!! NG- Hyperextend neck until you reach - ANSWER Resistance- meets nasopharyngeal NG- after meeting resistance - ANSWER Tilt head forward and have patient swallow small sips of water NG- immediately after placement of tube - ANSWER Check correct placement Aspirate gastric pH NG- after checking aspiration pH, get - ANSWER CXR- gold standard NG- if patient is on low-wall suction - ANSWER Stop for 30 minutes- 1 hour before feeding After NG insertion is done - ANSWER Leave patient HOB 30 degrees up Before giving IV push meds - ANSWER Compatibility of med with fluids Stop fluids with roller clamp/pause pump Aspirate for blood return Inject 2ml or so of flush After using push/pause method for IV bolus medication - ANSWER Perform the same for flush After line is clear, push 2-3 more mL Make sure to restart fluids Provider orders O2 at 45%- use - ANSWER Venturi Provider orders O2 at 4L for a post-op patient- use - ANSWER Nasal cannula with humidification Permits movement and communication 40% O2 ordered for a patient who is scared of the full mask-use - ANSWER 5L nasal cannula + humidity Or open face mask at 40% 82% O2 saturation- best device - ANSWER 100% non-rebreather Get oxygen to vital organs Car accident patient- order O2 at 50%- use - ANSWER Venturi with green attachment- 12L Be prepared to intubate if patient stops breathing Pneumonia- order O2 at 8L with target FiO2 of 60% - ANSWER Simple face mask Add humidity Prenant client is in active labor and fetus is in distress. O2 at 100%- use - ANSWER 100% non-rebreather- will provide the most oxygen The nurse has delegated administration of tube feeding to a specially trained UAP. Before the UAP administers the tube feeding, what action should be taken by the nurse in regard to this delegation? A) check tube for placement B) orders the equipment to give the feeding C) regulate the rate of feeding D) set up the equipment and mix the feeding - ANSWER A) check tube for placement Which of the following is true regarding traction? A) traction force enables the distal bone to remain in alignment with the proximal end B) traction pressure is used to keep bone fragments slightly apart C) patients with traction devices should be kept immobile D) patients with traction devices have decreased sensation and pulses in the limb distal to the fracture - ANSWER A) traction force enables the distal bone to remain in alignment with the proximal end A patient with a large infected wound needs negative-pressure wound therapy and asks the nurse how the technique works. Which statement by the nurse is most accurate? - ANSWER A measured foam pad is placed over the open area along with an occlusive dressing. Negative pressure removes drainage and contracts the wound bed. The nurse notes that a tube-fed client has shallow breathing and dusky color. The continuous feeding is running at the prescribed rate. What is the nurse's priority action? A) Assess the client's lung sounds B) Place the client in high Fowler's position C) Turn off the tube feeding D) Assess the client's bowel sounds - ANSWER C) Turn off the tube feeding The nurse has inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? - ANSWER Aspirate stomach contents and check the acidity using a pH test strip. As the nasogastric tube is passed into the oropharynx, the client begins to gag. What is the correct nursing action? A) Remove the tube and attempt reinsertion. B) Give the client a few sips of water. C) Use firm pressure to pass the tube through the glottis. D) Have the client tilt the head back to open the passage. - ANSWER B) Give the client a few sips of water. Identify the correct technique for cleaning a surgical wound with a drain. - ANSWER Clean any drainage tube sites using a full circle; beginning at the drain insertion site and moving in a circle outward from the drain The priority nursing action for a patient with a traction device is which of the following? A) Provide psycho-social support to prevent depression and isolation B) Provide pain medication frequently to prevent distress C) Monitor circulation of the limb distal to the fractures D) Clean pin sites every four hours with hydrogen peroxide - ANSWER C) Monitor circulation of the limb distal to the fracture