Nursing Fundamentals II

Diagnostic Testing

100

First morning void is thrown out and the rest kept on ice

What is a 24 hour urine specimen collection

200

A method of injecting a dye into an artery and obtaining an x-ray of blood vessels

What is an angiography?

300

A way to show density of tissues and organs indicating malformations, or tumors also called computed axial tomography.

What is a CT scan?

400

Monitors kidney function

What is BUN and Creatinine?

500

Actions when gathering a wound culture

Cleanse the wound and any residual ointment or cream with Normal saline, ensuring the sample provided is from the wound itself and no surrounding superficial skin

Key Terms

100

Performed to obtain bone marrow, liver cells, or spinal fluid

What is aspiration?

200

Blood in urine

What is hematuria?

300

Obtaining a CBC, chemistry, or serology test 

What is a venipuncture

400

Electrical conductivity of the brain

What is an EEG?

500

Glucose in the urine

What is glucosuria?

Assisted Feedings

100

Biggest priority when administering enteral nutrition

Vomitting/Aspiration

200

During the transition to no longer provide PN, what is the proper way to discontinue that administration?

Discontinuation should be done gradually to avoid rebound hypoglycemia.

300

Rules for continuous feedings

*Must name minimum 4

• Flush the enteral tubing with at least 30 mL water every 4 to 6 hr, and check tube placement again.
• Monitor intake and output and include 24-hr totals.
• Monitor capillary blood glucose every 6 hr until the client tolerates the maximum administration rate for 24 hr.
• Use an infusion pump for intestinal tube feedings.
• Follow the manufacturer’s recommendations for formula hang time. Refrigerate unused formula, and discard and change bag Q 24 hr.
• Some facilities require gastric residual volume checks, typically every 4 to 6 hr. Check facility protocol for specific actions to take for the amount of residual. 
• Do not delegate this skill to assistive personnel.

400

WORTH DOUBLE

Nursing actions when providing an enteral feeding

*Must provide minimum of 5 answers total*

• Prepare the formula, tubing, and infusion device.
  • Check expiration dates and note the content of the formula.
  • Cleanse top of can with alcohol to remove germs and bacteria
  • Ensure that the formula is at room temperature.
  • Set up the feeding system via gravity or pump.
  • Mix or shake the formula, fill the container, prime the tubing, and clamp it.
• Assist the client to semi-Fowler’s position or elevate the head of the bed to a minimum of 30°.
• Auscultate for bowel sounds.
• Monitor tube placement.
  • Check gastric contents for pH. 
  • Aspirate for residual volume. 
  • Note the appearance of the aspirate.
  • Return aspirated contents, or follow the facility’s protocol.
• Flush the tubing with at least 30 mL water.
• Administer the formula.

500

WORTH DOUBLE!!!! 

Proper intraprocedure for nasogastric tube insertion in the correct sequence.

*Must provide a minimum of 6 steps in order*

• Auscultate for bowel sounds, and palpate the abdomen for distention, pain, and rigidity.
• Raise the bed to a level comfortable for the nurse.
• Assist the client to high-Fowler’s position (if possible).
• Assess the nares for the best route to determine how to avoid a septal deviation or other obstruction during the insertion process.
• Use the correct procedure for tube insertion, wearing clean gloves, and evaluate the outcome.
  • Determine tube length ...
• If the client vomits, clear the airway, and provide comfort prior to continuing. 
• Check placement. Aspirate gently to collect gastric contents, testing pH (4 or less is expected), and assess odor, color, and consistency.
• After placement verification, secure the NG tube on the nose
  • Confirm placement with an x-ray. QEBP
  • Injecting air into the tube and then listening over the abdomen is not an acceptable practice.
• If the tube is not in the stomach, advance it 2.5 to 5 cm (1 to 2 in).
• Clamp the NG tube, or connect it to the suction device.

What diet is that?

100

A regular diet modified in texture and includes foods that require minimal chewing before swallowing 

Mechanical soft diet

200

This diet includes clients who have chewing or swallowing difficulties, oral or facial surgery, and wired jaws. 

Blenderized liquid (pureed) diet

300

Acceptable foods are water, tea, coffee, fat-free broth, carbonated beverages, clear juices, ginger ale, and gelatin.

Clear liquid diet

400

Prescribed when swallowing is impaired with manifestations of drooling, pocketing food, choking or gagging.

Dysphagia diet

500

Food supplements/snacks in between meals to add calories but are low in fiber and predisposes clients to constipation

Soft (bland, low-fiber) Diet

The Collection

100

Results between 70 mg/dl to 200 mg/dl

What is blood glucose?

200

Process of dipping a strip into a urine sample

What is urine glucose testing? 

300

Involves stool and screens for colon cancer 

FOBT (Fecal Occult Blood test)

AKA Guiac test 

Avoid - vitamin C up to 3 days prior to collecting stool for an FOTB can lead to a false-negative result. Melons, radishes, and turnips can lead to a false-positive.

400

The use of a towelette each time to cleanse from an area of least contamination (front) to an area of greater contamination (back)

Midstream collection

500

This is obtained in the morning, before a meal, and saved into a sterile container after rinsing the mouth with water.

Sputum collection

Complications & What to Do

100

Cramping

• Consider a change in formula.
• Decrease the flow rate or total volume of the infusion.
• Increase the volume of free water if constipated.
• Administer the EN at room temperature.
• Take measures to prevent bacterial contamination.

200

Cracking.

 “Cracked” TPN solution has an oily appearance or a layer of fat on top of the solution and should not be used

300

Metabolic

Hyperglycemia, hypoglycemia, hyperkalemia, hypophosphatemia, hypocalcemia, dehydration (related to hyperosmolar diuresis resulting from hyperglycemia), and fluid overload (as evidenced by weight gain greater than 1 kg/day and edema).

400

Dumping

Rapid emptying of the formula into the small intestine, resulting in a fluid shift. Manifestations include dizziness, rapid pulse, diaphoresis, pallor, and lightheadedness.

500

Infection and sepsis

Evidenced by a fever or elevated WBC count. Infection can result from contamination of the catheter during insertion, contaminated solution, or a long-term indwelling catheter.

It is essential that the nurse monitor the IV insertion site