Ch 31
Name 3 of the 7 rights of medications.
1. The right medication - verify order and that it is the correct medication = Compare the label of medication with MAR 3 times (before removing form med drawer/cabinet; when removing from container; and at bedside when administering)
2. The right dose - Proper medication calculation/pump set up - unit-dose helps minimize errors
3. The right patient - Use two patient identifiers and barcode scanning to verify correct patient.
4. The right route - Follow ordered route - contact provider if one is not provided.
5. The right time - Consider frequency of medication frequency and timing required for particular medications
6. The right documentation - Document accurately at time of med admin - patient's full name, full name of medication, time of admin, and dosage, route and frequency of admin
7. The right indication - Make sure the medication is being used appropriately - medication reconciliation can help ensure proper ordering
Name one example of an isotonic exercise.
Walking, swimming, jogging, bicycling - activities that cause muscle contraction and change in muscle length (isotonic contraction)
Name a late sign of hypoxia.
Central cyanosis
The nurse is administering blood within the 4 hour infusion time and notices that the patient is exhibiting a temperature of 101.7 deg F. The nurse stops the blood transfusion Name the next priority action prior to discontinuing the IV catheter.
Start normal saline at rate to keep vein open using new tubing.
List the steps of the nursing process.
Assessment
Analysis and Diagnosis
Outcome Identification and Planning
Implementation
Evaluation
The length of needle that would be used for a deltoid injection on an adult patient.
1 - 1/2 inches. The gauge of the needle would be 25 gauge (smaller gauge number = larger the needle diameter; Ex18 gauge is larger than 25 gauge).
Subcutaneous injections - shorter needles 3/8-5/8 inch.
See Skill 31.5 Administering injections - Needle Length for immunizations p. 691
The nurse uses this piece of equipment to assess orthostatic hypotension.
Blood pressure cuff
Name 2 effective ways to prevent pneumonia and get patients to clear airways.
Cough (use of the huff technique), deep breathe, turn - should be done every 2 hours; Incentive Spirometry (IS); Ambulating
Name 2 assessment findings of an IV that has infiltrated.
Edema of the extremity near the insertion site; Skin discolored or pale in appearance; Skin cool to the touch; Skin taut/shiny
Assessment information that comes from what the patient reports [ex. "I'm nauseated and don't feel good." or "I have a headache."] is considered this type of data.
Subjective
This is the angle that the syringe enters the skin for an insulin injection.
45 - 90 degrees (subcutaneous = insulin)
Intradermal (TB or tuberculin test) - 5-15 degrees
Intramuscular (IM) - 90 degrees
Name 1 consideration for safe patient handling when preparing to move a patient who is able to assist.
Face the direction of the movement; Use proper body mechanics; Keep a wide base of support; Keep the body's center of gravity low; Use arms and legs; Leverage, rolling, turning, or pivoting requires less work than lifting
Name a nursing diagnosis that would be priority for a patient who has pneumonia with a respiratory rate of 30 breaths/min and heart rate of 110.
Impaired gas exchange
0.225% NaCl (1/4 NS) and 0.45% NaCl (1/2 NS) are examples of this type of solution.
Hypotonic solution (have effective osmolality less than body fluids)
A label that is given to the assessment data that has been collected by the nurse and determines the next steps of planning the interventions.
Nursing diagnosis
The steps of the nursing diagnosis development include:
Observation of the patient and consideration of their medical diagnosis
Organization of the data
Interpretation of the information
Write the diagnostic label
Write an etiology
This is done to a vial before inserting the needle to prevent infection.
Clean with alcohol swab and allow to dry.
This is one of the five components of mobility assessment that determines the degree of limitation or injury to a joint. It can determine extent of joint stiffness, swelling, pain, limited movement, and unequal movement.
Range of Motion - ROM
Name 2 considerations when suctioning a patient with a tracheostomy.
Limit length of suctioning to 10 seconds; Do not apply suction when inserting the catheter; Apply intermittent suction when removing gently rotating and removing the catheter; Set suction from 80-150 mm Hg; monitor O2 saturation; Hyperoxygenate (if warranted) before and after
In the steps of an IV insertion, the nurse will apply the tourniquet and select the vein. The nurse then releases the tourniquet before doing this next step.
Clean the site - then reapply the tourniquet, insert vascular access device, and advance and secure.
This is used to determine the effectiveness of nursing care.
Evaluation
Name the three main sites for intramuscular injections.
Ventrogluteal (adults, children and infants - preferred for deep IM injections - large volumes and more viscous and irritating like antibiotics)
Vastus lateralis (used in adults and is preferred site for immunizations for infants, toddlers, and children)
Deltoid (Used in adults - potential for injury due to nerves; Use for small med volumes; Used for immunizations in toddlers, older children, and adults)
This is a postural disorder noted by a lateral S- or C-shaped spinal column with vertebral rotation, unequal heights of hips and shoulders (can be caused by congenital, idiopathic, and neuromuscular disorders)
Scoliosis
This oxygen delivery device should only be used for oxygen rates of 10-15 L.
Non-Rebreather mask
This is the formula used to determine pack-years.
Packs per day X number of years smoked = pack-years
Ch 30 - Lung assessment
Number is used as a screening tool providing cumulative exposure indicator of smoking burden and used to assess risk for developing smoking-related diseases for clinical practice, research, and healthcare policy.
These are the actions/skills performed by a nurse in the implementation phase [ex. ADL training and exercise, diagnostic-patient monitoring, pressure injury prevention methods, oxygen therapy, teaching-coaching]
Nursing interventions or interventions
Would accept direct or indirect care or patient cares.