Injections
What should the nurse do if there is no wheal forming during an intradermal injection?
Pause injection, pull back slightly keeping the bevel under the skin, continue to inject looking for a wheal.
What are do not crush medications?
Extended release medications (CR, ER, XR, SR, CRT, DR)
What 5 spots do we listen to for a cardiovascular assessment? What are the landmarks for each?
Aortic valve -right 2nd intercostal space RSB
Pulmonic valve-left 2nd intercostal space LSB
Erb’s point- left 3rd intercostal space LSB.
Tricuspid- 5th intercostal space LSB
Mitral valve- Left 5th intercostal space, midclavicular line.
You are assessing a patient who is able to only able to resist against gravity. What muscle strength rating would you give this?
3
What are they types of aphasia?
Receptive- Difficulty receiving information but able to express needs.
Expressive- Difficulty expressing needs but able to receive and understand information
Global- Difficulty expressing and receiving information
Why does the nurse utilize the z-track IM method? Where is it best to to administer?
Used for irritating/staining medications. Helps keep medications where they are meant to stay. Vastus Lateralis/ Ventrogluteal
Describes the step for administering eye drops.
Clean eyes, tilt head back, have patient look up, pull down lower lid, drop medication into lower conjunctival sac, hold light pressure over inner canthus.
Wait 5 mins between eye drops/ointments
What is a pulse deficit? How do you assess for it?
It occurs when the heart is contracting, and the pulse is not reaching the periphery. Usually caused by irregular heart rhythms.
Calculate by having one nurse taking an apical pulse and another nurse taking a peripheral pulse. Subtract the peripheral pulse rate from the apical pulse rate to determine if there is deficit.
How do you perform ROM exercises?
Support below the joint
Do not push pass the point of pain or resistance.
What nerve is cranial nerve III and how is it assessed?
PERRLA
Don't remove air bubbles, administer into compressed skin, patient laying flat
What happens during your 1st, 2nd, and 3rd medication checks?
1st check- 5 rights, gathering medications
2nd check- 5 rights, DDCC, expirations dates
3rd check- scan barcode (if applicable) 5 rights, prepare medications
What does the heart sound S2 signify and where is it best heard?
Caused by closing of the Aortic & Pulmonic valves
Termination of Ventricular Systole & start of Ventricular Diastole (filling)
Best heard 2nd Right ICS. (aortic area)
Exaggerated curvature of the lumbar spine. Who is this common in?
Lordosis.
Common in obesity and pregnancy.
What test is commonly used to assess level of conscience? What would be a normal and abnormal finding?
Glasgow coma scale
Normal score of >14, abnormal score 3
Explain the steps for preparing mixed insulin.
Complete 2 checks, 5 rights.
Inject air into NPH, Inject air into Regular, Draw up Regular, (2nd nurse check) Draw up NPH (2nd nurse check).
Complete 3rd check
Before administering an inhaled medication, the nurse should assess this to determine how effective the treatment will be.
The patient’s respiratory status (lung sounds, rate, and effort)?
Pulses are present, Edema is present, pain present when dependent but reduced with elevation, skin is warm. What type of insufficiency is this?
Venous Insufficiency
Give an example of 3 questions you would ask when gathering subjective data for the MSK system.
Injury, Pain, stiffness, medications taken, personal/ family history.., surgeries, occupation physical or sedentary, exercise etc.
Describe the 2 ways to assess tactile discrimination
Stereognosis- having the patient close their eyes and identify a familiar object in their hand
Graphesthesia- having the patient close their eyes and identify a number or letter that is traced in their palm
Give the needle size length and gauge ranges for ID, SQ, IM injections.
ID: 26-27 g 3/8-1/2 in
SQ: 25-31 g 1/2-5/8 in
IM: 18-25 g 5/8 -1 1/2 in ----> Typically 1-1 1/2 in in adults
Before administering a PRN medication, the nurse must first do this.
Complete assessments to order parameters are met (i.e. the patients need for medication) and when the medication is last administered.
This heart sound is normal in trained athletes and older patients after exercise. It is best heard 4th or 5th Left ICS.
S4
What do you assess for inspecting the MSK system?
Muscle mass, Joint structure, color, edema, crepitus, ROM, Symmetry
COMPARE BILATERALLY!
What are 3 reflexes that are considered normal in infants? What happens for these reflexes?
Rooting-turns head to side when cheek stroke
Moro-sudden jarring or noise-extension and abduction of extremities
Babinski-extension and abduction of toes with sole stroking
Palmer grasp- flexion of fingers
Sucking- to feed