Question | Answer |
What FR size is used for chest tubes? | 14 F for uncomplicated cases, 18 F for thick secretions. |
nerve block | anesthetic agent is injected around a nerve or group of nerves. Major (brachial plexis - arm) and minor (facial) |
hypovolemic shock signs | rapid, weak pulse, dyspnea, tachypnea, restlessness and anxiety, urine less than 30mL/hour, decreased BP, cool clammy skin, thirst, pallor |
Define bolus feeding | use a syringe to deliver the formula |
Hyperoxygenation of client on ventilator: | turn it on 100% O2 for 2 minutes prior to suction/trach care |
Veins used for IV infusion in the hand/arms | metacarpal, basilic, cephalic |
P wave | depolarization of atria (sinus node) |
Patients are released from PACU when . . . | conscious, oriented, able to breathe freely, cough, stable vital signs for 30 minutes, protective reflexes (gag, swallow) intact, move all extremities, I&O 30ml/hr, afebrile, dressings dry/intact, no overt drainage |
Insert the suction catheter ___ inches. Withdraw the catheter ___ cm before applying suction to prevent damage to bifurcation of trachea. | 5 inches, 2 cm (0.4 to 0.8 inches) |
How to measure an NG tube | measure from the tip of the nose to the tip of the earlobe, and then down to the tip of the xiphoid. |
Every time you change an IV site, you have to move ___. | up from the last site. |
If a pt with a chest tube gets more than ___mL/hr it is a hemorrhage | 100 |
For a butterfly needle, insert it in the direction of ___. | blood flow. |
A double-lumen NG tube is used for: | suctioning the stomach of secretions. The larger lumen allows delivery of liquids or removal of secretions. The smaller lumen allows for airflow into the stomach, which prevents vacuum pressure in the stomach/adherence to the stomach wall. |
Hyperinflate with ambu bag: | 3-5 times before performing suction or trach care. Do not do this if the client has copious secretions, as it can cause the secretions to go further down in the airway. |
For continuous feedings, check residual every ___hours. | 4-8 |
Why does diabetes mellitus have increased surgical risk? | Delayed wound healing, predisposes patient for wound infection |
60-cycle interference | electrical problems with ECG unit |
The use of what meds can increase surgical risk? | anticoagulants; tranquilizers; cortocosteriods; diuretics |
For transfusion therapies use a ___ gauge IV catheter. | 20 |
Position during immediate postanesthetic stage for an unconscious client. | On the side, face slightly down to allow drainage. No pillow. Elevate upper arm on pillow to allow maximum respiration. Artificial airway remains in place until client starts to gag/cough. |
Assessing surgical wounds (6) | appearance (color, approximation of wound edges); size, drainage (color, consistency, odor, degree of bandage saturation); swelling; pain, drains or tube (security, placement, character of drainage, functioning of drainage apparatus) |
What do you ask the patient to do during removal of the chest tube? | valsalva maneuver |
Peripherally inserted central venous catheters (PICC lines) are usually placed ____. The advantage of a PICC line is ___. | in the basilic or cephalic vein just abouve or below the antecubital space of the right arm with tip resting in superior vena cava. Eliminates risk of pneumothorax. |
wandering baselines | caused by breathing and electrodes moving too much during ECG |
What do nurses assess post-operatively? | LOC; vital signs; skin color/temp; comfort; fluid balance; dressing & bedclothes (for hemorrhage); drains and tubes. |
pneumothorax | air in the pleural space |
Do not draw blood ___ an IV site. | above |
If more than ___mL is aspirated when checking residuals before the next feeding, check with the nurse in charge or agency policy. | 100 |
topical anesthesia | applied directly to skin, mucous membranes, wounds. Xylocaine & benzocaine |
Guidelines for cleaning a wound with a penrose drain | The Penrose drain is considered to be less clean than the surgical incision because of the drainage from the Penrose drain. Clean the main surgical incision first. Then clean the Penrose drain using different equipment/dressing/cleaning supplies. |
What is the formula for calculating gtts/min? | (volume/hour x drip factor on bag) divided by 60 min |
QRS complex | depolarization of ventricles |
Define cyclic feeding | continuous feeding that is administered in less than 24 hours (12 or 16 hours, usually overnight) |
V1 | 4th intercostal space to right of sternum |
When using a dry suction unit for chest tube collection, set the wall suction at ___ to achieve a -20 pressure on the unit. | at least 80 |
When trying to get an IV placed, the RN should only try __ times before getting another RN. | 2 |
V3 | between V4 & V2 |
When removing tape, pull the tape ____ the wound. | Towards- to prevent straining the incision. |
embolus | clot that has become dislodged |
Closed systems of formula can hang for | 48 hours if sterile technique is used |
Health problems that increase surgical risk | Malnutrition; Obesity; Cardiac complications; Blood coagulation disorders; Upper Respiratory/COPD; Renal disease; Diabetes mellitus; Uncontrolled neuro disease (seizures) |
What position should the client's head be in when inserting an NG tube? | hyper-extend the neck to reduce the curvature of the nasopharyngeal junction. |
V2 | 4th intercostal space to left of sternum |
Open systems of formula can hang for | 8-12 hours |
Sequential signs of healing for primary intention (surgical) wounds | 1. Absence of bleeding/formation of clot; 2. inflammation of wound edges for 1-3 days; 3. reduction in inflammation, bridge and closed in 7-10 days; 4. scar formation; 5. diminished scar over time |
Place the tourniquet ___. It should not be kept on longer than ___. | 6 inches above the site. 2 minutes. |
If using forceps to assist in cleaning a wound . . | keep the forcep tips lower than the handles at all times to prevent contamination and fluid traveling up the handle and to the nurse's wrist, and back to the tips. |
For neonates or clients with fragile veins use ___ gauge IV catheter. | 24-27 |
TKO | "to keep open" referring to the order to keep the IV open and flow moving. Usually set to 20-30mL/hr for this purpose |
Post-op patient vital schedule | every 15 minutes until vital signs stable; every hour for the next four hours; every 4 hours for the next 2 days. |
V6 | mid-axillary line, horizonal V4 |
Pneumonia signs | elevated temperature, cough, expectoration of blood-tinged or purulent sputum, dyspnea, chest pain. |
When the ___ , a pt with a chest tube is considered healed. | tidal stops moving |
How long can catheters last? | 2-4 days |
hemothorax | blood in the pleural space |
hemorrhage signs | excess bleeding, increased pain, increased abdominal girth, swelling or bruising around incision |
If a chest tube becomes clotted, ___. | contact the physician. Don't try to unclot it yourself. |
Gastric pH should be at: | 1 to 5. 6 or grater indicates the tube is in the respiratory tract or lower in the intestinal tract. |
What is a nasoenteric tube? | a longer tube (longer than the NG tube) that is inserted into the top part of the small intestine. |
Why does liver disease have increased surgical risk? | impairs ability to detoxify/metabolize meds. Liver makes proteins (prothrombin for clotting and others for wound healing). |
When using a prefilled bottle for tube-feeding, hang it on an IV pole about ___ inches above tube insertion point. | 12 |
Basilic vein is on the __ side of the arm. The Cephalic vein is on the __ side of the arm. | Basilic- pinky; Cephalic- thumb |
When changing bandages that involve a Penrose drain, | make sure not to pull the bandage off without making sure that the drain is not attached to the bandage! Sometimes the drain may stick to the bandage. |
local anesthesia (infiltration) | injected into a specific area. Lidocaine & tetracaine 0.1% |
V4 | mid-clavicular line & 5th intercostal space |
thrombus | stationary clot |
pulmonary embolism signs | sudden chest pain, SOB, cyanosis, shock (tachycardia w/ low BP) |
Why is obesity an increased surgical risk? | leads to hypertension, impaired cardio function, impaired respiration. Delayed would healing b/c adipose tissue impedes circulation. |
atelectasis signs | dyspnea tachypnea, tachycardia, diaphoresis, anxiety, pleural pain, decreased chest wall movement, dull/absent breath sounds, decreased O2 sat, sudden chest pain, SOB, cyanosis, shock (tachycardia w/ low BP) |
thrombophlebitis | inflammation of veins: aching, cramping pain, affected area swollen, red and hot to touch, vein feels hard, discomfort in calf when foot is dorsiflexed or when client walks (Homan's sign) |
What kind of needle/catheter should be used for which circumstance when drawing blood? | tube holders- standard; syringe- fragile veins; butterfly- large amt. of blood being taken, children, or difficult sticks. |
epidural (peridural) anesthesia | injected med into epidural space, the area inside the spinal column but outside dura mater. |
When placing an NG tube, and the client begins to gag and retch, what should the nurse do? | Ask the client to tilt the head forward and encourage the client to drink and swallow. Tilting the head forward facilitates passage of the tube into the posterior pharynx and esophagus rather than the larynx. |
Allow ____ minutes between suctions to allow for client recovery. | 1 minute |
How should the NG tube be guided in? | direct the tube along the floor of the nostril and towards the ear on that side. This avoids nasal turbinates along the lateral wall. |
T wave | re-polarization of ventricles |
How long can bags hang (saline)? | 24 hours |
The over-the-needle catheter should be inserted at __ angle. | 15-30 degrees, with bevel up |
Label the IV site with: | date, time, size of catheter, and initials |
What should the setting be when using suction? | 80-120 |
What does a nurse assess in a pt with a chest tube? | crepitis, constant air flow in the unit (instead of normal tidal volume). |
When prepping an area for IV/vein puncture ___. | use a chloroprep to go vigorously back and forth. |
Why does renal disease have increased surgical risk? | Regulation of body fluids, electrolyte, acid/base balance, excretion of drugs and toxins |
How long can TPN hang? | 24 hours |
When puncturing a vein, do NOT ___. | put your finger above the needle! |
V5 | between V4 & V2 |
Define continuous feeding | administered over a 24 hour period at a constant flow |
intravenous (Bier) block | occlusion tourniquet is applied to prevent infiltration/aborption beyond the extremity. Used most for arms, hands & wrists. |
For routine hydration and intermittent therapies use a ___ gauge IV catheter. | 20 (ideal) to 27 |
Before removing an NG tube: | instill 50mL of air into the tube to clear it of gastric contents. |
artifact | during an ECG, when the patient is moving or when using electrodes that are too dry. Abnormal reading. |
Isotonic Solutions | Normal Saline (0.9% NaCl); Lactated Ringers; D5W (5% dextrose in water) |
How long can IV tubing last? | 2 days |
conscious sedation | minimal depression of LOC so client can retain patent airway and respond to commands. IV narcotics: fentanyl, diazepam (valium), Versed. Induces amnesia and higher pain threshold, prompt reversal of effects. |
spinal anesthesia (SAB- subarachnoid block) | lumbar puncture between L2 and S1. Low (saddle block- perineal/rectal); Mid (below umbilicus- hernia, appendectomies), High (reaching nipple line- csections) |
pleural effusion | fluid that accumulates in the pleural space of the lungs |
Where is a specimen collected from a chest tube? | Directly from the tube. Not from the collection unit. |
A central venous catheter is usually placed in ___ and the end is__. Risks include___. | subclavian or jugular vein, with distal tep resting in the superior vena cava just above the right atrium. Risks include hemothorax, pneumothorax, cardiac perforation, thrombosis, infection. |