GI
GI
GU
Oxygenation
Oxygenation
100
What are methods to check NG placement?
test pH with strip; xray.
100
What steps must the nurse take to prevent aspiration when removing an NG tube?
Clear the tube with 30 ml of air or NS and have the pt take a deep breath and hold it.
100
Your pt has a foley and c/o severe abd pain. You note no drainage in the foley. What is your first action?
Check for kinks in foley and reposition the pt
100
What are some things that affect the body's ability oxygenate itself?
HGB level, dec in O2 inspired, hypovolemia, inc metabolic rate, trauma to resp center or spinal cord; chronic disease
100
Your pt is quite elderly. List some nursing diagnoses that would reflect the disorders they're at risk for developing b/c of aging.
ineff airway clearnace impaired gas exchange risk for infection
200
What is the difference between a jejunostomy feeding and a gastrostomy feeding?
A jejunostomy feeding tube is placed within the jejunum b/c the pt has a stomach issue that prevents gastric emptying. A gastrostomy feeding is placed within the stomach.
200
What nursing assessments must be performed before removing an NG tube, regardless of doctor's orders?
auscultate for bowel sounds; assess that there is no further drainage of stomach contents other than normal mucus
200
Hypoventilation causes what acid-base imbalance? What conditions produce hypoventilation? Hyperventilation causes what acid-base imbalance? What conditions produce hyperventilation?
resp acidosis; COPD, pneumonia resp alkalosis; anxiety, panic attacks, fever, pregnancy
200
Describe in detail how you would react if you walked into a pt's room and they were in respiratory distress.
First, talk calmly and be confident and in charge. Get eye level with pt and assist them to perform pursed lip breathing or diaphragmatic breathing; if they're already on O2, check for proper flow rate, that it is flowing, no kinks in tubing, etc. Administer meds as ordered: bronchodilators, steroids, mucolytics, anti-anxiety; DB&C; postural changes
300
How do you prevent gastric contents from flowing out of the NG tube pig tail and onto the pt or bed?
Keep the pig tail above the level of the stomac at all times.
300
What should you observe for if your pt has had an NG tube for a a few days after stomach surgery such as a partial gastrectomy?
electrolyte imbalances
300
If your pt has a suprapubic catheter, where is it located on the body?
lower abdomen
300
How do you treat resp alkalosis? resp acidosis?
alkalosis: treat underlying cause; rebreathe exhaled air from a paper bag. acidosis: postural drainage, DB&C, bronchodilator, maintain airway, prepare for intubation
300
List different types of adventitious breath sounds and describe what they sound like
Wheezing: high pitched, musical Crackles: sound of air through mucus: sounds like hair rubbed together in front of ears; can be fine or coarse diminished: air exchange is heard, but not loud or full friction rub: loud, harsh grating sound from inflammed pleura
400
What assessments will you make when your pt has an NG tube for stomach decompression?
obs for signs of abd distention, n/v, bloated feeling, increasing SOB, increase in abd girth, assess contents draining from NG: amount, color, characteristics, odor; assess bowel sounds; note naris for pressure; cond of oral mucosa
400
What is a priority assessment before beginning a tube feeding?
verify tube placement
400
Your pt c/o not voiding in 8 hrs and has a strong urge to urinate. Your first nursing action:
palpate for a bladder to see if the bladder is full or over-distended
400
What would the numerical value of a pH be if the pt is in resp acidosis? if in resp alkalosis?
acidosis: below 7.35 alkalosis: above 7.45
400
Discuss several methods to keep lung secretions mobile and to promote lung expansion
increasing PO fluids, humidification of room, med-neb, CPT with postural drainage, positioning, I.S.,
500
What would you do if your pt's NG tube has not drained anything in 4 hours? Describe all the specifics of the procedures you would perform
First, try to reposition the patient to see if that starts drainage again. If not, irrigate the NG with 30 ml normal saline, unless contraindicated . Add this to intake on the I/O;
500
What precautions should the nurse take to prevent aspiration when the pt is receiving tube feedings?
elevate HOB 30 degrees, check for residual q4h
500
Your pt has had a foley in for 24 hours. The doc just ordered a urine for C&S. How will you obtain this sterile specimen. Describe all steps.
Clamp off the foley tubing by kinking it and wrapping with a rubber band just below the "Y" connector where you inflate the balloon for 10-20 minutes. When urine is observed at the port site, cleanse the port with betadine, let air dry, then aspirate urine with a sterile needle and sryinge. Inject the urine into a sterile urine cup; need at least 10-30 ml.
500
What element in an ABG reflects if the kidneys are trying to compensate for resp acid-base imbalances?
HCO3 (bicarb)
500
Discuss several safety factors when a pt is using o2, whether at home or in a facility
NO SMOKING signs, nothing flammable on or around the equipment, cotton linens, grounded electrical equipment, fire extinguisher nearby; home evac plan for fires,
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