Chest Tube Management
What color chest tube drainage would alarm the nurse?
Bright red blood
How long does the nurse have to complete the blood transfusion?
4 hours
You are giving your patient Zofran via IV push. You have administered your medication and are preparing to flush your line. What rate should you push the saline?
At the same rate as your Zofran.
You assess your patient and find their PICC catheter's external visual length has changed. What symptoms would you expect your patient to be experiencing?
Irregular pulse & heart palpitations
When are PVC's most dangerous?
You hear the student nurse encouraging your patient with a chest tube to cough and deep breathe every 1-2 hours. As the primary nurse, what actions would you take?
Reinforce this teaching
Your patient is blood type AB-. What types of blood can they RECEIVE?
A-, B-, AB-, O-
Describe infiltration and hematoma
Infiltration: skin in edematous and cool, feels rigid
Hematoma: a raised area of skin that is ecchymotic
What are 4 indications a central venous catheter may be inserter rather than a peripheral IV?
Long term abx (7 days or more)
Frequent lab draws
No peripheral access
Chemotherapy
TPN
Trauma
Your patient is in first-degree heart block. As the nurse, what should be your priority intervention?
Monitor the patient for progression to a more serious block
You suspect an occlusion in your patients chest tube. What symptoms might they be exhibiting?
Shortness of breath and low oxygen saturation.
List 3 of the most common signs/symptoms of an allergic reaction to a blood transfusion?
(pruritus, urticaria, erythema)
Describe the process for administering an IV push medication through a primary line with an incompatible solution.
Stop the primary infusion
Flush the line with a saline flush
Push your medication
Flush the line with a saline flush
Restart the primary infusion
Describe the process for selecting the best nostril for NG tube insertion.
Examine the nose for symmetrical nostrils/septal deviation
Assess history of facial surgeries/trauma
History of nose bleeds/sinusitis
Which AV block is characterized by a PR interval that progressively lengthens until a QRS is dropped?
Type 1 second degree AV block
You see continuous bubbling in your patient's wet suction chest tube. What action should you take?
You see intermittent bubbling in your patient's wet suction chest tube. What action should you take?
Begin to clamp on the proximal end until you identify the location of the leak.
Continue to monitor
You are administering blood to a patient diagnosed with heart failure. What interventions are most important?
Assess respiratory status
Administer diuretics as needed
What should the nurse do if there is bleeding noted at the IV insertion site?
Assess the IV site
List 3 things you would teach your patient following insertion of a PICC line.
Keep the clamps closed when exposed to air
Cover the site when bathing or showering
Notify your provider of upper extremity soreness
Avoid sports
Keep sharp objects away from the catheter
Avoid swimming
Your patient is in atrial fibrillation. Their 6 second ECG strip shows a heart rate of 44bpm. What should you do as the nurse?
Assess their pulse
Describe 3 purposes of chest tubes
Aid in expansion of lungs
Reestablishes negative pressure in the intrapleural space
Prevents air or fluids from re-entering the pleural space
Describe 4 symptoms of acute hemolytic reaction
Chills, shaking, 2 degree F increase in temperature, increased pulse, IV site pain, nausea/vomiting, chest tightness, headache, flank pain, hypotension
You are pushing an IV medication and your patient becomes flushed in the face and complains of chest tightness.
1.What is your patient likely experiencing?
2.How could you prevent this in the future?
1. Speed Shock
2. Push the medication at prescribed rate
What factors should be considered before NG tube removal?
Abdominal assessment - return of bowel sounds?
Order
Have contents decreased or stopped?
Nausea?
Your patient is unresponsive and pulseless. Their telemetry is showing ventricular tachycardia. What 3 actions will the nurse take?
Call for assistance and a defibrillator
Begin CPR while waiting for a defibrillator
Defibrillate the patient