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112-T2 Skills
| Question | Answer |
|---|---|
| Which statement might a nurse make to nursing assistive personnel (NAP) when caring for a patient prescribed an intravenous (IV) bolus of analgesic medication? | “Let me know immediately if the patient complains of pain at the insertion site.” |
| Which patient safety issue is specific to administration of medication by IV bolus? | Determining that the medication is compatible with the IV solution |
| Medication that is incompatible with the running IV solution could | form a precipitate and endanger the patient’s health |
| What is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus? | Injecting the medication at the prescribed rate is the most important action the nurse can take to protect the patient when administering a narcotic analgesic by IV bolus, since injecting the medication faster than recommended may result in injury or death |
| How can the nurse best minimize the patient’s risk for infection when administering an IV bolus of an analgesic? | Follow aseptic technique during the entire process. |
| If the nurse does not see blood return when aspirating the saline lock in preparation for an IV bolus medication, what is the next step? | Blood return may be absent with a smaller-gauge catheter. Infusing normal saline while checking for infiltration ensures that the catheter tip is both patent and in the vein |
| For IV Bolus label all syringes of IV push medications or solutions unless the syringes are prepared | at the patient’s bedside and the medication is immediately administered without any break in the process. Use bar code scanning or similar technology immediately before administration. |
| when delivering an IV bolus always select | the needleless injection port of the IV tubing closest to the patient |
| For IV Bolus disinfect the connection surface and sides of the needleless connector using | vigorous mechanical scrubbing for a minimum of 5 to 15 seconds, using a flat swab pad containing 70% isopropyl alcohol or alcohol-based chlorhexidine solution suitable for use with medical devices. Allow the solution to dry. |
| The typical size range for IV push syringes is | 3 mL to 10 mL |
| To inject IV bolus | occlude line by pinching just above injection port; stop infusion if fluids are being administered; pull back to aspirate, if patent, pinch IV line while pushing and release while not pushing; if IV fluids compatible allow to infuse when not pushing medication |
| If IV Bolus is incompatible prepare | >two 10 mL NS syringes to flsuh >clamp, flush with NS, push medication, flush with NS, unclamp tubing >clean port with sterile swab before/after each step, allowing to dry between each step |
| When preparing for transfusion (class): | - check provider orders - 2 nurse verification - take vitals - do not heat in microwave - instruct on sign/symptom of transfusion reaction-1) unexplained fever, 2) decrease in hemoglobin or hematocrit (2-14) days later |
| midline Catheter (class) | - check provider orders - check patency of line - check for swelling/ infiltration - flush before/after medication admin - make sure line is dry, clean, and intact - instruct patient to avoid getting catheter wet/ submerging in water (use waterproof covering before taking shower) |
| central venous access device (CVAD) (class) | -prevent CLABSI - hand hygiene, max barrier precautions, chlorhexidine skin antiseptic, daily review of line and prompt removal -observe for leaks, kinks, obstructions, or coils -instruct pt on flushing technique, dressing changes -assess for pain, swelling, tenderness -use sterile technique with insertion -instruct pt to report discomfort around the site, arms, shoulders, or side of neck, or any shortness of breath |
| initiating a blood transfusion (class) | - 2 nurse check - NS w/ Y tubing (blood specific tubing) - run at 2 mL/ min for first 15 minutes - remain w/ pt for first 15 minutes - check vitals every 15 minutes for first hour - teach pt adverse reactions and instruct to tell nurse -- back pain, hives/itching, impending doom, difficulty breathing |
| Performing Tracheostomy care (class) | - limit suction to 15 sec - turn suction device on and set vacuum device regulator between 180 and 120 - notify provider about signs of infection - keep trach obturator at bedside to facilitate reinsertion of a dislodged outer cannula - if long term placement is anticipated, plan to educate pt and family on trach care--clean trach, clean exposed outer cannula and surfaces and stoma under flange using NS (cleaning in a circular, expanding motion) |
| Monitoring for Adverse reactions to transfusion (class) | - teach pt about possible signs of transfusion reaction - monitor for vital signs - if pt states having chills, stop infusion return blood and blood administration set to blood bank - initiate cpr is cardiac arrest occurs - replace with NS if reaction occurs - for respiratory distress, administer Epinephrine |
| While checking a blood product prior to administration, the nurse is called away to assist with another procedure. What should the nurse do with the blood product? | Return it to the blood bank until it can be administered |
| An infusion of blood or blood products must be initiated within 30 minutes of obtaining the unit from the blood bank. If the infusion cannot be initiated within that period, the blood must be returned to the blood bank until the infusion can be initiated. | 30 |
| While checking a blood product prior to administration, the nurse notices that the birth date on the blood bag and requisition do not match the birth date on the patient’s identification bracelet. Which is the correct action for the nurse to take? | If there is any discrepancy in the patient’s birth date or other identifying information, the product must not be administered. Notify the blood bank and other appropriate personnel, as indicated by your agency’s policy. Return the blood to the blood bank |
| An adult patient is prescribed to receive a unit of packed red blood cells. Which size intravenous catheter does the patient need to safely receive this blood? | 18-gauge |
| Blood should be administered to an adult using a | 14- to 24-gauge short peripheral catheter (per Lab Skill) |
| The nurse is preparing to administer a unit of blood to a patient in the emergency department and discovers that he is not wearing an identification bracelet. What should the nurse do? | Since blood products must not be administered to any patient who is not wearing an identification bracelet, the nurse must return the unit to the blood bank. Even if the patient is conscious and awake |
| While checking a blood bag prior to infusion, the nurse notes that the patient’s blood type is A+ and the donor’s blood type is O+. Which action would the nurse take? | Administer the blood. A patient whose blood type is A+ can receive blood from a donor whose blood type is O+. The donor and recipient blood types are compatible, so there is no need to return the blood to the blood bank. |
| A patient prescribed to receive two units of packed red blood cells is to receive a dose of intravenous medication between the two units. How would the nurse administer the medication? | Through another IV line. Medication is never injected into the same IV line used for a blood component. |
| The nurse is preparing equipment to administer a unit of blood to a patient. Which type of fluid would the nurse piggyback with the blood transfusion? | 0.9% normal saline. Blood and blood products can be administered only with 0.9% normal saline. No other solution is to be administered or piggybacked with blood or blood products |
| A patient is to receive one unit of packed red blood cells over 2 hours. Which rate is the usual flow rate for the first 15 minutes of a blood transfusion? | 2 mL/ min |
| When would it be appropriate to increase the transfusion rate of blood to 25 mL/min? | after the first 15 minutes of the transfusion. |
| Max infusion time for blood is | 4 hours, starting from when blood is removed from refrigeration |
| A patient is to receive 3 units of packed red blood cells over 8 hours. What will the nurse do to maintain the patency of the patient’s IV access line after each of the first two units of blood has transfused? | Infuse 0.9% normal saline at the KVO rate. |
| A patient received two 300-mL units of packed red blood cells, and the line was flushed with 25 mL of solution between the units. What is the total amount of fluid the nurse will document having provided to the patient? | 625 mL |
| A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse’s first action? | Stop the transfusion. |
| A patient has a blood transfusion reaction, and the transfusion is stopped. What should the nurse do with the remaining blood and transfusion administration set? | Return both to the blood bank. |
| A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient’s vital signs after stopping the transfusion? | Every 15 minutes |
| A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication? | To relieve respiratory distress |
| It is determined that a patient who received a blood transfusion received an infection from the blood. Whom should the nurse notify of this infection? | Blood bank and infection control department |
| A nurse is educating a patient with a new midline catheter. Which of the following teaching points should the nurse emphasize? | Do not disrupt the dressing on the midline catheter because this may lead to infection at the catheter exit site |
| A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient? | A gauze dressing placed over catheter exit site |
| A gauze dressing should be used with a patient who ________excessively because it wicks the moisture away from the catheter exit site | perspires |
| When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next? | Notify the practitioner |
| A nurse is flushing and locking a midline catheter through a positive displacement valve needleless access device. When should the nurse clamp the catheter? | After removing the syringe |
| A nurse is teaching a new nurse about midline catheters. The new nurse is asked about which intravenous infusions can be administrated through a midline catheter. Which of the following responses would indicate the new nurse needs more teaching? | Central parenteral nutrition |
| Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? | “Let me know immediately if the patient’s dressing becomes damp.” |
| Which action would the nurse take to minimize the patient’s risk for infection when changing the dressing on a CVAD? | Use sterile technique throughout the process. |
| How can the nurse minimize the risk of dislodging the catheter when removing a dressing? | Remove the transparent dressing or tape and gauze in the direction of catheter insertion. |
| What will the nurse do after removing the soiled dressing from a patient’s CVAD device? | Remove the catheter stabilization device, if present. |
| What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? | Change the dressing every 48 hours. |
| How can the nurse best minimize a patient’s risk for infection during tracheostomy care? | Adhere to sterile technique when appropriate. |
| Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? | Keeping an obturator and a tracheostomy tube at the patient’s bedside |
| Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? | Cleaning and assessing the skin around the stoma |
| Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? | Holding the tracheostomy tube while the nurse changes the neck ties |
| Which technique would the nurse use to change a patient’s tracheostomy ties? | Ensure that two fingers fit snugly under the tie. |
Created by:
cnblake1
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