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ADN Midterm
| Question | Answer |
|---|---|
| What gauge is a blue cannula? | 22 |
| What gauge is a green cannula? | 18 |
| What gauge is a pink cannula? | 20 |
| How can a patient lose fluids? | vomiting, diarrhea, gastric suctioning, intestinal fistulas, intestinal drainage, diuretic therapy, renal disorders, endocrine disorders, sweating from excessive exercise, increased environmental temperature, hemorrhage, chronic abuse of laxatives |
| What is insensible water loss? | fluid lost on a daily basis from the lungs, skin, respiratory tract, and water excreted in the feces. The exact amount cannot be measured, but it is estimated to be between 40 and 600 mL in an adult under normal circumstances (NO ELECTROLYTES ARE LOST) |
| What are some causes of fluid loss in the older adult? | self limiting of fluids (fear of incontinence), physical disabilities, cognitive impairments, older adults without air conditioning |
| What is the lab value for hypercalcemia? | Greater than 10.2 mg/dl |
| What are some S&S of hypercalcemia? | decreased memory, confusion, disorientation, fatigue, constipation, flank pain, ekg changes, vital sign changes |
| What kinds of vital sign changes can you see in a patient with hypercalcemia? | Early increase in heart rate, then bradycardia that can progress to cardiac arrest. You may also see hypertension in patients with hypercalcemia. |
| What is the lab value for hyperkalemia? | greater than 5.5 meq/L |
| What are the S&S of hyperkalemia? | weak or paralyzed skeletal muscles, V-fib or cardiac standstill, abdominal cramping or diarrhea, EKG changes |
| What was the food Kristi told us to remember was high in potassium? | Orange juice however don't give orange juice to people with renal failure |
| What are good sources of magnesium? | black beans, broccoli and halibut |
| What is the average amount of water that can be lost in urine per day? | 1500 ml |
| What are the 5 proper steps for a blood transfusion? | 1. verify the orders, pt id and blood compatability 2. assess the iv site 3. take an innitial set of vital signs 4. pick up the blood from the lab 5. start the transfusion |
| What do you do if your patient has a fever when you take the innitial set of vital signs prior to blood transfusion? | call the dr |
| What should the RN verify that the MD obtained prior to transfusion? | informed consent |
| What fluid do you use to prime the line and start the iv prior to blood transfusion? | .9 NS |
| What gauge cannula do you use with a blood transfusion? | 20 gauge or larger (the smaller the number, the larger the gauge) |
| Do you need a filter in the tubing when administering whole blood? | YES |
| What information do 2 RN's need to verify prior to transfusion? | client's information, type of transfusion, name, birthday, MR#, unit#(identical on bag and requisition), blood type and rh factor, expiration date |
| Will you see signs and symptoms of a transfusion reaction immediately? | yes and no. Delayed reactions can occur days to months after a transfusion which can be manifested by increased temperature, decreased hematocrit and mild jaundice |
| What are the four types of transfusion reactions? | hypersensitivity, febrile, hemolytic, bacterial |
| What are the signs of a hypersensitivity transfusion reaction? | fever, uticaria (hives), anaphylactic shock |
| What are the signs of a febrile transfusion reaction? | increased temperature, nonspecific, most common |
| What are the signs of a hemolytic transfusion reaction? | caused by blood incompatibility: nausea, vomiting, lower back pain, tachycardia, hypotension, hematuria, decreased urine output |
| What are the signs of a bacterial transfusion reaction? | septicemia from contaminated blood products: fever, chills, tachycardia, hypotension and shock |
| What is anaphylactic shock? | The flood of chemicals released by immune system can cause blood pressure to drop,airways narrow, blocking normal breathing. Signs and symptoms of anaphylaxis include a rapid, weak pulse, a skin rash, and nausea and vomiting. |
| What question can you ask a patient to determine if they are at a higher risk for a trnsfusion reaction? | Have they ever had a blood transfusion before. Greater risk of complication with each transfusion. (I think Kristi said problems after 10) |
| What is your patient at risk for if they receive a rapid transfusion of blood products? | circulatory overload |
| What are assessment findings for fluid overload? | tachycardia, bounding pulse, hypertension, distended neck veins, crackles, dependant edema, taunt skin, low urine specific gravity, weight gain |
| What interventions might be used to manage circulatory overload? | decrease flow rate, elevate HOB, watch for dysrhythmias, notify dr, O2, morphine sulfate for vasodilating |
| What medication might be given for a hypersensitivity transfusion reaction? | benadryl (airway management, O2, treat shock) |
| What medication might be given for a febrile transfusion reaction? | premedication with tylenol or asprin (airway management, O2, supportive care) |
| What medication might be given for a hemolytic transfusion reaction? | benadryl (airway management, O2, supportive care) |
| What medication might be given for a bacterial transfusion reaction? | ATB, fluid recuscitation, vasopressors, corticosteroids (blood will need to be cultured) |
| What steps should you take when your patient has a transfusion reaction? | 1)stop transfusion 2)maint. iv access &.9NS, 3)assess,vs q5min DO NOT LEAVE the PATIENT 4)call blood bank &dr 5)provide supportive care 6)draw blood sample 7)obtain UA -hematuria 8)return blood bag, tubing, labels, and transfusion record to blood bank |
| What do you need to consider before administering antibiotic IV piggyback? | Is drug compatible with primary solution? Does the patient have allergies? Is the drug compatible with IV administration? |
| After evaluating compatability, what are the steps you take to hang an IV piggyback of antibiotics? | verify med, prepare med, spike IVPB with secondary tubing, connect secondary tubing to port on primary tubing,ensure the connection is above the pump house,if fluid is running-no need for saline flush,if not flush with 2-3 ml of saline, set pump and start |
| After you have started the infusion, what do you need to do? | monitor the infusion and document |
| If a patient experiences a complication with IV therapy, what is your first step? | STOP THE INFUSION. Treatment will be specific to the type of complication |
| What is extravasation? | leakage of a vesicant into surrounding tissue, stop the transfusion and call dr and pharmacy to determine appropriate protocol |
| What is infiltration? | leakage of a non-vesicant solution into surrounding tissue. S & S include coolness around skin, taut skin, edema around the site, absence of backflow, pinkish blood return, slow infusion rate |
| What are the s & s of hematoma? | discoloration of the skin surrounding the venapuncture, site swelling and discomfort, inability to advance the cannula during insertion, resistance of positive pressure when flushing |
| What steps can you take you take to prevent hematoma? | use indirect method, apply tourniquet just before venapuncture, use smaller gauge in elderly and patients taking steroids, use BP cuff in elderly instead of tourniquet, be gentle |
| What can you do to treat hematoma? | apply direct, light pressure with sterile gauze pad over site for 2-3 min, elevate extremeity over pt's head or on a pillow to maximize venous return, ice may be applied to prevent enlargement |
| How can you prevent thrombosis? | it is a clot, use pump to prevent blood from backing up into tubing, use microdrip tubing when rate is below 50 ml/hr, avoid placing iv in area of flexion, use filters, avoid cannulation of lower extremities |
| How can you treat thrombosis? | never flush to remove the clot, discontinue and restart in a different site, notify dr and assess site for circulatory impairment |
| What are S & S of phlebitis? | reddness at site, warm to touch, local swelling, PALPABLE CORD alonf the vein, sluggish infusion rate, increased boby temp of 1 degree or more |
| How can you prevent phlebitis? | use large veins, central lines or picc's for long term or hypertonic solutions, use smallest cannula possible for solution, rotate site Q72-96 hrs, stabilize catheter, use good handwashing and IV techniques, change solution containers Q 24 hours |
| What is the phlebitis scale 0-4? | 0.no symptoms 1.reddness with or without pain 2. reddness, pain and/or edema 3. reddness, pain and or edema, streak formation, palpable cord 4. reddness with pain and/or edema, streak formation, palpable cord greater >1 in. in length, purulent drainage |
| Does the risk of phlebitis increase after the first 24 hours? | yes |
| When should peripheral iv's be changed? | every 48-72 hours or as needed |
| What solutions pose a greater risk for phlebitis? | dextrose, KCl, ATB, Vit C. They have a lower pH and are associated with a higher risk of phlebitis |
| What is the treatment for phlebitis? | discontinue the infusion, apply warm or cold compresses, consult with physician |
| Are S&S of infiltration and extravasion seen immediately? | yes and no, could take days or weeks to develop |
| What is a compartment? (as in compartment syndrome) | muscles nerves and vessels are all in compartments confined in flexible spaces bound by skin, fascia and bone. |
| What is compartment syndrome? | When fluid inside the compartment increases, the venous end of the capillary bed bed becomes compressed. S & S: pain, vascular spasm, muscle necrosis |
| What is a rating of 0 the infiltration scale (0-4)? | 0. no symptoms |
| What is a rating of 1 the infiltration scale (0-4)? | 1. skin blanched,edema < 1in., cool to touch, with or w/out pain |
| What is a rating of 2 the infiltration scale (0-4)? | 2. skin blanched, edema 1-6 inches, cool to touch, with or w/out pain |
| What is a rating of 3 the infiltration scale (0-4)? | 3. Skin blanched and translucent, gross edema >6 inches, cool to touch, mild to moderate pain, possible numbness |
| What is a rating of 4 the infiltration scale (0-4)? | 4. skin blanched and translucent, skin tight, leaking, gross edema >6 inches, deep, pitting tissue edema, circulatory impairment, moderate to severe pain |
| How can you prevent infiltration? | frequent assessment of site and both extremities, check for blood return (if you suspect infiltration: apply pressure 3 inches above site to see if infusion stops running, if not, suspect infiltration |
| How do you treat infiltration? | stop the infuse and restart in another site, apply cold compresses and elevate extremity, if too painful to elevate allow patient to find comfortable position |
| What are the S & S of extravasation? | complaints of pain or burning, swelling proximal or distal to the iv site, puffiness of the dependant part of the limb, tauntness at site, blanching and coolness of skin, slow or stopped infusion, damp or wet dressing |
| How do you treat extravasation? | stop the infusion and leave cannula inplace until treated, give antedote, remove cannula, cold compresses 24-72 hours, photograph per policy, elevate arm 4 in., call dr, document details, file an unusual occurance per policy |
| What can cause local infections r/t iv therapy? | catheters left in place longer than 72-96 hours, field sticks not changed after 24 hours, poor technique in placing catheter, poor technique maintaining and monitoring the peripheral site |
| How are local infections r/t iv therapy treated? | call dr, remove the cannula, culture tip and site and do blood cultures, apply sterile dressing, ATB as ordered, monitor the site |
| What is Best Practice when handling and discontinuing and IV? | proper handwashing technique and maintain sterility as much as possible |
| What is the most accurate way to infuse? | using the Alaris pump |
| What is the normal range for sodium? | 135 - 145 |
| What is the normal range for potassium? | 3.5 - 5-5 |
| What is the normal range for magnesium? | 1.5 - 2.5 |
| What is the normal range for calcium? | 8.5 - 10.2 |
| What is the normal range for phosphate? | 3.0 - 4.5 |
| Can you take a BP in an arm with a PICC? | NO |
| (Patient teaching) Does a patient need a medic-alert bracelet if they have an implanted device for long term use? | yes |
| (Patient teaching) Are there any activity restrictions for patients with a PICC or CVAC? | no |
| (Patient teaching) Can a patient with a PICC and non-implanted CVAD bathe or swim? | no |
| (Patient teaching) Can a patient with an implanted CVAD swim or bathe? | yes - when it is not being accessed |
| How should you care for a central line insertion site? | use air occlusive dressings (tegaderm) and they chould be changed if the become soiled or loose. Follow policy for dressing changes every 2-7 days. A gauze dressing must be changed within 48 hours but a transparent dressing can be left on for 7 days. |
| How do you change a central line dressing? | STERILE procedure, use sterile gloves and mask (nurse and patient). Clean area 2 inches in diameter around the site using chlorhexidine swab. Use circular motion starting at center and work outward. Allow to dry. Apply chlorhexidine gel. Apply tegaderm |
| What are the steps to properly start an IV? | prepare client, open and prepare infusion set, spike solution container, hang solution on pole, partially fill drip chanber, prime tubing, label container and tubing, apply timing label to container |
| What supplies do you need to discontinue IV? | 2X2 gauze, clean gloves, tape |
| How do you discontinue IV site? | gather supplies, explain procedure, wash hands, turn off iv, apply gloves, loosen dressing wile keeping catheter stabilized, apply gauze over site, remove catheter, press down, hold 2 min, inspect cath tip, document, check in 15 minutes |
| How long do you apply pressure after d/c an iv in a patient taking blood thinners? | 5 minutes |
| What equipment do you need to innitiate iv therapy? | catheters and needles (angio), infusion pump, regulatory devices, tubing, filters (clean gloves, adhesive tape or securement device, iv pole, tubing, syringe and med if giving iv med via push) |
| What are the special considerations when starting an IV on pediatric patients? | Use numbing cream (EMLA 30-60 mins prior), use paci, special blanket or toy, immobilize child, mummy immobilize if needed, keep child warm, keep parent in room IF they keep child calm, DISTRACT, hang no more that 500ml (250ml for under 12 mos.) monitor! |
| What kinds of things should you look for while changing a dressing on a PICC? | inspect for redness, swelling, tenderness, drainage, compare length of external portion of catheter with documented length to assess for displacement |
| Do you change dressing on peripheral IV? | yes, if they become soiled or not forming a seal around site. Use clean gloves, clean site with chlorhexidine, apply tegaderm |
| What are the special considerations for starting an IV on an elderly client? | veins may be more fragile, leave tournequet on a minimal amount of time, use 5-15 degree angle when inserting needle into superficial veins, site stabilization harder with loose skin, may develop fluid imbalances r/t more extracellular fluid volume |
| Are they elderly at a greater risk of fluid overload and/or fluid deficit? | yes |
| Can you use a BP cuff as a tournequet in older adults with delicate skin? | yes |
| What are the three types of chemotherapy? | 1. Neo-adjuvant 2. Adjuvant 3. Palliative |
| When is Neo-adjuvant chemotherapy used? | BEFORE surgery to shrink a tumor so it is easier to remove |
| When is adjuvant chemotherapy used? | AFTER surgery to make sure that any cancerous cells are killed |
| When is palliative chemotherapy used? | for ADVANCED cancer. Used to prolong life and slow progress of disease. |
| What additional two areas of the body can be used for IV therapy in infants under 18 months? | feet and scalp |
| Who has more body water, men or women? | men (adipose tissue does not have water content and women have more adipose tissue) 50-55% adult women and 55-60% adult men |
| How much body water do the elderly have? | 45-55% (less than adults therefore greater risk for fluid volume deficits) (elderly women at greatest risk!) |
| How much body water do infants have? | 70-80% also higher risk for fluid volume deficits |
| Who is the environmental theorist who pioneered concepts of light, cleanliness, ventilation, warmth, diet and noise? | Flo |
| Which theorist is known for fundamental NEEDS and The Nature of Nursing? | Virginia Henderson |
| Which nursing theorist is known for the science of CARING? | Jean Watson |
| Which nursing theorist's theory is Novice to expert? | Patricia Benner |
| Which nursing theorist is the Nursing Process Theorist? | Ida Jean Orlando |
| Which nursing theorist is the CULTURE theorist? | Madeline Leninger |
| Which nursing theorist is the Theory of Health as Expanding Consciousness Theorist? | Margaret Newman |
| Which nursing theorist proposed the Behavioral Systems Model? | Dorothy Johnson (Johnson-behave!) |
| Which nursing theorist proposed the thoery of Goal Attainment? | Imogene King (the King's gold) |
| Which nursing theorist proposed the three levels of prevention (primary, secondary, tertiary)? | Betty Newman |
| Which nursing theorist proposed the Self Care Deficit? | Orem |
| Which nursing theorist proposed the Adaptation model? | Sister Callista Ray (Ray-adapts) |
| Which nursing theorist is known as the mother of psychiatric nursing and proped the theory of interpersonal relations? | Peplau |
| What is primary prevention? | Prevention, to protect oneself against environmental risks. Immunizations, sun screen, nutritious foods. |
| What is secondary prevention? | Screenings, early detection and diagnosis, TB screen, Breast screen, Testicular screening. |
| What is tertiary prevention? | Rehabilitation, obtain medical treatment for illness or disease. |
| Who proposed hierarchy of needs, prioritize care based on the basic needs to sustain life before we move to other considerations | Maslow |
| What are Maslow's hierarchy of needs? | In this order: Physiological, safety, love and belonging, esteem, and self-actualization. |
| What are the S & S of hypocalcemia? | positive Chvostek's or Trousseau's sign, tetany, laryngeal stridor, dysphagia, tingling around the mouth or extremities, increased GI motility and cramping, anxiety, irritability, decreased HR and hypotension, EKG changes |
| What are venous spasms? | sudden, involuntary contraction of a vein or an artery resulting in temporary cessation of bloof flow through a vessel. R/T cold infusates, irritating solution, too rapid administration of IV solution or viscous solution. |
| How do you check placement of a central line? | it must be verified by x-ray |
| What do you need to check before starting TPN? | make sure Dr order was written prior to TPN bag change, keep TPN in refridgerater until 30-60 minutes prior to admin. the bag tubing and filter must be changed every 24 hours, check bag against the dr's order, inspect bag to ensure no fat globules present |
| Does TPN have to be administered using a pump? | yes |
| Can you start TPN at the physician's prescribed rate? | NO - must be started at a slow rate (50ml/hr) and gradually increased |
| How often are TPN bags, tubing and filters changed? | 24 hours |
| What do you need to monitor once TPN has been started? | blood glucose Q6H (hyperglycemia), strict I&O, daily weight monitor lab values (electrolytes, albumin, liver function) |
| Can you ever catch up TPN if it has fallen behind? | NEVER. Call the Dr. |
| How do you D/C TPN? | taper rate down slowly to prevent hypoglycemia |
| Can the catheter used for TPN be left in 72-96 hours? | yes. just bag, tubing and filter need to be changed Q24H |
| Can you give a piggyback into a line used for TPN? | NO |
| What is it called when a nurse engages in a helpful, empathetic, respectful relationshop with patient and family? The nurse has the client's best interst at heart and is goal oriented. | Therapeutic communication |
| What does SOLAR mean? | SQUARELY face the person, OPEN your posture, LEAN towards the sender, EYE contact maintained, RELAX while attending |
| Some other points to remember for therapeutic communication: | use broad ended questions, clarify, reassure and acknowledge the patient. Do not talk about yourself, and be aware of tone posture and pace. Always explain procedures and ask permission to touch them before doing so. |
| When is parenteral nutrition used? | when the GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients. The goal of PN is to meet nutritional needs, allow growth of new body tissue, and deliver fluid volume. |
| Do dextrose and lactated ringers provide nutrition? | yes, about 170 calories per liter and NO protein |
| When is TPN used? | if a person has INCREASED nutritional needs due to trauma, burns, surgery or malnutrition |
| What does TPN contain? | dextrose, water, protein, electrolytes, vitamins and trace elements |
| Can TPN be administered through a peripheral IV? | NO. Must be administered through a central line whose tip lies in the superior vena cava. |
| How often do you need to change tubing and filter for PN that only includes amino acids or electrolytes or dextrose? | 72 hours |
| How often do you need to change tubing for PN containing lipids? | 24 hours |
| Is infection a complication of TPN? | YES! That is why you have to change the tubing, filter and bag Q24H |
| What do you do if your patient's TPN runs out and you do not have another bag to hang? | Hang D10 solution right away to prevent hypoglycemia |
| What kinds of metabolic problems can occur with TPN? | hyperglycemia, hypoglycemia, increased nitrates (prerenal azotemia), fatty acid deficiency, electrolyte imbalance, hyperlipidemia, and mineral deficiencies |
| What are some mechanical problems that can occur with TPN therapy related to incorrect insertion? | dislodgement, thrombosis of great vein, and phlebitis |
| How long does it take to administer a unit of blood? | 2-4 hours |
| How do you correct a document error? | draw a single line through the erroneous entry and write the time, date and your name/innitials. Make the correction in a way that preserves the original entry. |
| Does TPN require a filter? | yes |
| What type of catheter has a valve at the tip of the catheter which makes it unnecessary to leave a high concentration of heparin in the catheter? | a closed tip catheter aka Gershong |
| What is the name of the open tipped catheter primarily used for pediatric patients? | Broviac catheter |
| What do you call the adult sized open tipped catheter which opens directly into the bloodstream? | Hickman catheter |
| On a closed tip/Gershong catheter, why is there a valve at the tip? | to prevent the backflow of blood |
| What are the advantages of a Gershong/closed tip catheter? | decreased risk of air emboli or bleeding, no need for heparin flush, no need to clamp catheter, reduce flushing protocols between use. |
| What are some best practices to use when hanging an IV bag? | check connections for leaks, d/c solution and remove iv if no blood return is present or flow rate is not acceptable, check for infiltration and phlebitis. |
| What should you teach the patient when innitiating IV therapy? | call nurse if flow stops, if solution container is low, if blood backs up into the line, or if they experience discomfort or swelling at the site. |
| What is maintenence therapy? | therapy to maintain daily body fluid requirements |
| What is replacement therapy? | replaces present losses |
| What is restoration therapy? | therapy for concurrent or continuing losses |
| What is a delayed complication that can occur in those who have received repeated blood transfusions? | Iron overload (it is a delayed reaction) |
| What are S & S of iron overload? | nausea, vomiting, hypotension, elevated iron levels |
| How is iron overload treated? | with Desferal. Urine will look red during excretion of the iron. Monitor iron levels. |
| How often do you take vital signs when administering a blood transfusion? | after first 15 minutes (you have remained with client first 15 minutes), then again at 1 hour, then again at the completion of the transfusion. |
| Should you place the blood administration sheet in the appropriate place on the chart? | yes |
| Should you change the blood set every 4 hours or with each unit of blood? | yes |
Created by:
Merrill15888
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