Vital Signs
A pulse that is palpable and graded as a 3+ is considered what?
Strong or Increased
0 = pulse that is absent/nonpalpable
+1 = pulse that is weak/diminished
+2 = pulse that is normal
+3 = pulse that is increased/strong
+4 = pulse that is bounding
How often should an immobile patient be repositioned/turned?
At least every 2 hours
When cleaning a sterile dressing the nurse knows to clean from “dirty” to “clean”.
True or False?
False
Clean from clean to dirty.
Example incision should be cleaned before drain.
A nurse is caring for a patient who had tuberculosis (TB). What PPE needs to be donned before entering the patient’s room?
A fit tested N-95 mask (or disposable respirator)
Gloves and gown
Face shield/goggles if indicated
What kind of precautions are these consistent with?
What is granulation tissue?
Reddish healthy tissue with a cobblestone appearance.
When mixing insulins (modified and unmodified) what is the second step?
Inject air into the unmodified (clear) insulin.
Your patient has bilateral soft limb wrist restraints in place. What is important to assess while a patient has restraints applied?
Circulation, skin integrity, sensation
The nurse notices that the patient has peripheral IV in the left forearm. The hub is pink, the nurse knows that the size of the IV catheter is what?
20 gauge
A patient is receiving IV therapy. Upon assessment it is noted that the patient’s IV site is cool, pale, and edematous. The nurse knows that this is what kind of IV complication?
Infiltration
What is a sign or symptom of chronic hypoxia?
Clubbing
hypercapnia
peripheral edema
right sided heart failure
Where should the drainage bag of a urinary catheter be placed?
Below the level of the bladder on a nonmobile part of the bed.
A nurse in inserting an ngt. She aspirates and tests the ph. The ph is 7.0. what does this tell the nurse about the position of the ngt?
It is not in the stomach- could be in lungs or intestines
When would clipping a clients toe nails be contraindicated?
If they have diabetes.
Which gases are primarily exchanged during respiration?
Carbon Dioxide and Oxygen
What is the range of motion movement in which a limb is moved in a circular motion?
circumduction
You are performing a sterile procedure. You notice there is a hole in your sterile glove. What do you do?
Stop procedure, remove gloves, discard sterile field, and start over with a new sterile field and gloves
When is it appropriate for healthcare providers to use handrub? List 3 instances.
•Before and after direct contact with patients
•After contact when hands are not visibly soiled
•After removing gloves
•Before donning gloves
•During care if moving from a dirty to clean site
•After contact with objects in patient’s environment
List three purposes of a dressing
Provide comfort
prevent infection
remove necrotic tissue
promote healing
The doctor has ordered a medication to be given intramuscularly. You plan to give it in the deltoid. What is the max amount of medication that can be injected into this site?
1 mL
What is the most common factor that puts someone at risk for falls?
Age 65 and older
Name 2 ways to dilate a vein
Apply and warm compress.
Place a tourniquet 4-6 inches above site of insertion
Pump fist
Massage in the direction of venous flow
A patient’s iv site is red, warm and painful. What complication is this?
phlebitis
What is the fio2 for 3lnc?
32 %
Name 3 ways utis can be prevented in the hospital
Only inserting foley when necessary
catheter care
check tubing for kinks
assess if catheter is still needed
keep bag below level of bladder
How do you remove an ngt?
Raise hob
disconnect suction
remove tape
clamp tube
have patient hold breath and remove
What is the best time to do a full skin assessment?
When giving a bed bath.
What is a normal BP level?
Less than 120/80
What complications of immobility is associated with the respiratory system? Name 2
Decreased movement of secretions
Thickening of secretions
atelectasis
pneumonia
Name 3 ways sterile technique can be broken.
Turning back on field
placing hands below the waist
leaving the room
touching sterile to nonsterile
spilling something on sterile field
reaching over sterile field
talking/coughing/sneezing over field
Define universal/standard precautions.
•An approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other bloodborne pathogens
•Standard precautions—used in care of all hospitalized patients
–Apply to blood, body fluids, secretions, excretions, nonintact skin, mucous membranes
What tissues may be exposed with a Stage 3 pressure ulcer.
Subcutaneous. Will not be able to see muscle, tendon, or bone.
This order is listed in your patient’s chart: Morphine 2mg PRN for severe pain.
What right of medication could be violated due to this incomplete order?
Right time. This order does not include the frequency at which the medication should be given.
What can be used to place in a patients mouth to keep them from biting their tongue during a seizure?
Trick question---nothing!!!
When is it okay to advance the iv catheter when starting an IV?
Once blood returns in the back flash chamber.
When do you retract the needle/stylet?
How do you manage phlebitis.
d/c iv site
relocate iv
warm, moist compress
How much fio2 can a nonrebreather mask give?
Close to 100%
What are two things to teach your patient that struggles with constipation?
Increase fluid intake
increase dietary fiber
increase activity
Name 2 purposes of an ngt
Decompression
feeding
medications
You are caring for a female client. You need to perform perineal care. What should you use to clean the clients perineum?
Plain soap and water.
When would obtaining an oral temperature be contraindicated? Name two examples
For a patient who is combative/agitated
A patient who has ate/drank/smoked /exercised in the last 30 minutes
An infant
How does immobility affect the GI system?
It slows peristalsis leading to constipation
A nurse is preparing a sterile field and spills sterile water on the sterile drape. What should the nurse do to make sure that surgical asepsis is maintained.
Discard sterile field and start over.
What are characteristics of the Prodromal phase of an infection? Name at least 2.
•The most contagious or infectious stage
•Early signs and symptoms are present but non-specific to disease
•Fatigue, low grade fever
•The patient is not usually aware that they are contagious
The nurse notices eschar on the patient's wound bed. They know what needs to be done for this type of tissue?
debridement.
When and why do you use the z-track method?
When giving an intramuscular injection
To prevent the medication from escaping the muscle to the surrounding tissue
What are 3 signs/symptoms of carbon monoxide poisoning?
Headache
confusion
loss of consciousness
nausea
breathlessness
collapse
death
A nurse is starting another iv following a previous iv site becoming edematous, red, and warm. Where should the nurse not attempt another iv site?
Below the site or
in the same vein.
What complication is this?
Name 3 signs/symptoms of fluid overload
Increase in Blood Pressure
Moist crackles
Cough with rapid/shallow breaths
Restlessness
Distended neck Veins
Edema/Weight Gain
How long should suctioning time last when performing NT suction on a patient?
10-15 seconds.
Do we suction while inserting?
What would warrant a 24hr urine test having to be restarted?
Patient voided in the toilet after the test has begun
How should the nurse confirm placement of an ngt after it is initially placed?
xray
Promotes circulation
Prevents infection
Helps with effects of immobility
Helps the patient feel better
What are two situations where vitals are out of a “normal” range but could be considered normal/acceptable for the patient?
A patient who runs everyday that has a lower heart rate.
A patient who has COPD and has a normal Fio2 around 88%
A patient who is thin and is otherwise healthy having a lower bp
Name three aspects of good body mechanics
Engage abdominal muscles when lifting
do not twist the torso
hold object close to you
bend at the knees when lifting
pivot
A nurse is about to perform a sterile procedure. Set up his sterile field and donned sterile gloves. If he touches the patients clean gown is sterility maintained?
no.
List the correct order of donning PPE.
1. Gown
2. Mask
3. Goggles/Face Shield
4. Gloves
What puts a patient at risk for decreased wound healing?
diabetes
immobility
infection
hypoxia
nutritional problems
tissue necrosis
How many times do you check a medication before you administer it?
List
When removing
preparation/after retrieval
in the patients room
What does the acronym race stand for?
R- rescue/remove
a- activate alarm
c- contain/confine
e- extinguish/evacuate
A patient comes into the ed following a mva. He is in critical condition and will likely require fluids and blood. The nurse should insert what size of IV?
18 gauge
Following IV fluids being started, your patient starts having dyspnea, excessive coughing, and complaints of palpitations. The nurse suspects that this is what IV associated complication? What interventions should be implemented?
Air embolus
Place pt on oxygen if ordered
Clamp IV line
Monitor VS
Position in Trendelenburg
You have a patient with copd that is feeling sob. His o2 sat is 89%. What should you do first?
Have the patient do pursed lip breathing
What position should the patient be in before administering an enema?
Left Sim's
What needs to be done before and medication or feeding is given through and ngt?
Check residual
check placement
When would using a regular razor on patient be contraindicated?
If they are on anticoagulants.