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Fund exam 4 ch 20
Fundamentals Exam #4 chapter 20 - Mrs. V's class
| Question | Answer |
|---|---|
| What is a gentle washing of an area with a stream of solution delivered through a syringe? | Irrigation |
| Irrigation should always be done in a direction from the inner to the outer or outer to inner of the canthus? | Inner to Outer |
| What word defines when the lumen of the blood vessel widens? | Vasodilation |
| When performing a warm eye compress the temperature of compresses should not exceed what temperature? | 120° F (49° C) |
| What word defines when the lumen of the blood vessel narrows? | Vasoconstriction |
| When performing an ear irrigation how should the patient be positioned? | Assist patient to either a side-lying or sitting position with head tilted toward affected ear and position emesis basin under ear. |
| When performing an ear irrigation, what temperature should the solution be? | Body temperature or 98.6° F |
| What is Tinnitus? | Ringing in the ear |
| What is Cerumen? | Ear wax |
| What is a piece of gauze dressing moistened in a prescribed warmed solution? | Compress |
| Moist heat promotes vasodilation or vasoconstriction? | Vasodilation |
| Patients with painful arthritis or other joint discomforts of the hands and feet benefit most from what type of bath? | Parafin baths |
| What is the mixture for a parafin bath? | 1 part mineral oil to 5 parts parafin |
| Cold compresses should be applied for how many minutes and at what temperature? | For 20 minutes at 59° F (15° C) |
| Cold compresses are used to relieve what? | Inflammation and edema. |
| What is administration of fluid, electrolytes, or nutrients through a needle or cannula inserted into a vein in the arm. | Peripheral IV Therapy |
| What type of therapy is administered through a catheter in the subclavian vein, jugular vein, vena cava, or right atrium. | Central Venous Therapy |
| What is Septicemia? | Blood poisoning |
| The nurse uses which method to determine the correct distance to insert a nasogastric tube? | Tip of nose to tip of earlobe to end of sternum. |
| After inserting a nasogastric tube, the nurse can be certain it is in the proper place if what? | If gastric contents are aspirated with cone-tipped syringe |
| Which part of the tracheostomy tube is removed by the nurse for cleaning? | Inner cannula |
| If, when suctioning a pt with a tracheostomy the nurse finds it necessary to repeat the interventions, it is recommended that the nurse wait at least 3 minutes. What does this allow for? | Replenishing oxygen |
| Preoperatively the physician orders “enemas until clear.” What are the maximum number of enemas the nurse should give? | Three |
| Which method is the most suitable for the nurse to use to prevent transmission of HIV or hepatitis B, C, and D during procedures associated with intravenous therapy? | Wear gloves |
| A pt complains of a headache & nausea during a blood transfusion. Which of the following actions should the nurse do immediately? 1. Check the vital signs2. Stop the transfusion3. Slow down the rate of blood flow4. Notify the physician and blood bank | Stop the transfusion |
| Which of the following is the least invasive alternative to urethral catheterization? 1. Suprapubic catheterization2. Reinsertion of a Foley catheter3. Catheter irrigation4. Condom catheterization | Condom catheterization |
| When irrigating a colostomy, the nurse uses a cone that fits properly to prevent: 1. introducing air into the colon.2. leaking of the solution around the stoma.3. administering the solution too rapidly.4. introducing bacteria into the stoma. | Leaking of the solution around the stoma |
| True or false: Some patients will have control over when they can evacuate their colon. | True |
| What are exercises that tighten the muscles of the perineal floor called? | Kegel |
| Bladder training involves developing the use of the muscles of the perineum to improve voluntary control over voiding; bladder training may be modified for different problems. What is the timing for control of leakage to develop? | 4-6 weeks |
| What occurs when pressure in the bladder is too great or because the sphincters are too weak? | Urinary incontinence |
| What is the method called where manual pressure over the lower abdomen is placed to express urine from the bladder at regular intervals? | Crede's Method |
| How far should the catheter be inserted for the male patient? | 6-7 inches |
| How far should the catheter be inserted for the female patient? | 2-4 inches |
| When inserting a catheter and urine flow is established, how much further should the catheter be inserted before inflating the baloon? | 1.5 inches |
| How often should the drainage receptable on a patient with a catheter be emptied? | At least every 8 hours or sooner if necessary |
| How often should catheter care be performed daily? | twice daily |
| In what position should the pt be in during the placement of a gastric tube? | High Fowlers with pillow behind head and shoulders |
| The CDC recommends that replacing the gauze and transparent dressing over a peripheral venous catheter site should occur at least how often? | Every 48 hours |
| What is the rationale of an eye irrigation? | To relieve inflammation, remove toxic substances, debridment of exudute |
| What is the manner of irrigating the eye and the purpose for doing it in this manner? | From the inner canthus to the outer canthus to prevent contamination and to prevent any further injury to the nasolacrimal duct |
| Reasons for ear irrigation? | To cleanse the canal of excess cerumen or exudate from a lesion or inflamed area. |
| What should the temperature of the solution be for the ear irrigation? | Body temperature or 98.6 |
| What are the contraindications for an ear irrigation? | if the patient has a cold, an elevated temperature, an ear infection, an injured or ruptured tympanic membrane |
| How do you position the patient? | Pt should be in either a side-lying or sitting position with head tilted toward affected ear and position emesis basin under ear with towel under the head. |
| When caustic chemicals enter the eye, the nurse must gently flush the eye continuously for how long and with what to prevent burning of the cornea and then refer the patient immediately to a physician | for 15 minutes with tap water |
| Assisted Personnel can be delegated eye or ear irrigations. True or False | False |
| What are the effects and indication of cold application | Vasoconstriction |
| What is the purpose of a cold compress | It is a temporary local anesthetic and numbs the area helping with the pain |
| When is a cold compress contraindicated | when there is swelling |
| What are the effects and indications of warm compresses? | |
| What should the temperature of the solution be for the ear irrigation? | Body temperature or 98.6 |
| What are the contraindications for an ear irrigation? | if the patient has a cold, an elevated temperature, an ear infection, an injured or ruptured tympanic membrane |
| How do you position the patient? | Pt should be in either a side-lying or sitting position with head tilted toward affected ear and position emesis basin under ear with towel under the head. |
| When caustic chemicals enter the eye, the nurse must gently flush the eye continuously for how long and with what to prevent burning of the cornea and then refer the patient immediately to a physician | for 15 minutes with tap water |
| Assisted Personnel can be delegated eye or ear irrigations. True or False | False |
| What are the effects and indication of cold application | Vasoconstriction |
| What is the purpose of a cold compress | It is a temporary local anesthetic and numbs the area helping with the pain |
| When is a cold compress contraindicated | when there is swelling because it will decrease circulation of the area |
| What are the effects and indications of warm compresses? | Vasodilation and increases circulation of the areal |
| When is a warm compress contraindicated? | On patients with cardiac problems because it compromised the circulation or if there is any inflammation or active bleeding |
| What is the difference between a aquathermia pad and a traditional heating pad | The aquathermia pad is able to maintain a consistent temperature |
| What are the complications of IV Therapy? | Infiltration, Phlebitis, Septicemia |
| What are the signs of Infiltration? | Swelling and hard and cold with soreness |
| What are the signs of Phlebitis? | Erythema, swelling and warmth |
| What are the signs of Septicemia? | Blood poisoning would show signs of fever, headache, chills, nausea, vomiting or general signs of infection |
| What would be the nursing intervention for IV complications? | Stop the infusion and restart in different location. |
| What is fluid overload? | an infusion rate that is too rapid resulting in placing too much fluid into the circulation and overload the cardiovascular, neurological, and urinary systems |
| What are the signs and symptoms of fluid overload? | dyspnea; a rapid, weak pulse; cough; disorientation; increased or decreased blood pressure; crackles; pitting edema; weight gain; and decreased urine output. |
| What would be the nursing intervention for a fluid overload? | immediately slow the infusion rate and contact the charge nurse |
| What is the nurses primary responsibility with a blood intervention? | Pre-transfusion: Positively ID the patient, take vitals and verify blood compatibility Post-tranfusion: continue to monitor patient |
| Once a blood tranfusion is started when do you recheck the vitals? | At 15 minute intervals |
| What are the reactions of a blood transfusion? | They may have chills, fever, low back pain, pruritus (itching), hypotension, nausea and vomiting, decreased urine output, chest pain, and dyspnea. |
| What is the nurses responsibility if a reaction to a blood transfusion is noted? | Stop the infusion and notify the charge nurse. |
| What is the purpose of oxygen therapy? | To prevent or relieve hypoxia |
| How should oxygen be treated? | As a drug |
| How can oxygen be modified? | Nasal cannula, face mask, through a trach |
| What is the usual flow rate of oxygen for a nasal cannula? | 2 L/min |
| What is the usual flow rate of oxygen for a face mask? | 6-10 L/min |
| What should be the older adult considerations with oxygen therapy? | Because normal arterial can be between 75 and 80 you should not go above a 2 L/min with a nasal cannula. If more is needed then a face mask should be used. |
| What is proper routine urinary catheter care? | Once per shift or 2 x per day/minimum. |
| How do we handle catheter care? | For female: Right side, left side and then down the center For the male: circular motion and down With a catheter from the urinary meatus clean outward about 4 inches |
| What is the nursing intervention post removal of a catheter? | Monitor the urinary functioning and the output of the patient to ensure they have voided within 8 hours from the removal of catheter |
| Can urinary catheter care be delegated to AP? | Yes |
| What are the different bowel diversions? | Colostomy, iliostomy |
| What is the difference between the colostomy and iliostomy in regards to site? | Colostomy is incising the colon and bringing it out to a stoma on the abdominal surface. Iliostomy is a surgical formation of an opening of the ileum onto the surface of the abdomen. |
| What is the difference between the colostomy and iliostomy in regards the characteristic of stool? | Colonscopy usually have a semi-solid of solid stool whereas Iliostomy is more liquid and can cause more irritation to the skin due to gastric contents not being absorbed. |
| What is the nursing care for bowel diversions? | Change the pouch every 3-7 days or PRN, assess the stoma for irritation |
| The primary responsibilities for nurses to patients with tracheostomy? | Maintain the patency on the trach site through suctioning and cleaning of the inner cannula |
| How do you clean the tracheostomy? | Clean the inner cannula with peroxide and then rinse with normal saline |
| When suctioning how far down do you go? | 5-7 inches |
| When performing a tracheostomy suctioning, how long do you suction for? | no more than 10 seconds |
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bsmymicareo
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