oxygen therapy
What positioning intervention is part of managing a patient's hypoxia?
Raising the HOB (high Fowler’s position) to promote chest expansion and reduce word of breathing.
Describe the different types of Wound Drainage
Sanguineous: Sanguineous exudate is fresh bleeding
Serous: Drainage is clear, thin, watery plasma. Small amounts are considered normal wound drainage
Serosanguinous: Exudate contains serous drainage with small amounts of blood present
Purulent: Exudate is thick and opaque. It can be tan, yellow, green, or brown. It is never considered normal
______ is a surgically created opening called a stoma that goes from the front of the patient's neck into the trachea?
What is a tracheostomy?
One 8 ounce glass of tea
Four 8-ounce glasses of water
5-ounces of apple juice
1 Tbsp of creamer
50mL/hr for 12 hours
1965 ml
What scale do nurses use when predicting a pressure score risk
What is the Braden Scale?
a splint
When completing a dressing change, what is the proper way to cleanse the wound
Clean incision first then move outward, incision must be cleaned from top to bottom
sterile technique
Order: 40 mg Tylenol liquid for a 3-day-old infant. Label reads: 160 mg/5 mL. How much will the nurse measure for this child?
1.25 mL
A wound with redness, warmth, tenderness, purulent or malodorous drainage
What is Signs and Symptoms of a Localized infection
A nurse assesses a client and notes an SpO₂ of 90% on room air, a respiratory rate of 26, and use of accessory muscles. The client reports feeling “short of breath and anxious.”
What is the nurse's best interpretation?
Client is showing early signs of hypoxia and needs prompt intervention
This type of dressing can be used on wounds with minimal or no exudate to retain moisture
What is a Transparent Film?
What is the main concept of changing trach ties?
New trach ties should be placed prior to removing the old one
The provider orders 1000mL IVF to infuse over the next 8 hours. What will you set the pump rate?
125ml/hr
Spontaneous opening of an incision which can often be caused by Excessive Coughing, Sneezing, Vomiting
What is a Dehiscence?
What are the steps to teaching a patient to use IS (incentive spirometry) & how often should the patient use it?
1. Sit upright
2. Breathe in slowly and deeply through the tubing
3. Hold breath for 5 seconds, or as long as tolerated
Repeat 10 times every hour while awake
Describe the components of a Wound Assessment
Location, Type of wound, Degree of tissue damage, Wound bed, Wound size, Wound edges and periwound skin, Signs of infection, Pain
Your patient has a fenestrated inner cannula and is in respiratory distress, what is your first step? Why?
Exchange the inner cannula prior to suctioning.
the fenestrated inner cannula could cause
major damage to the trachea during suctioning
100 mL Ceftriaxone Sodium 1G to infuse over 30 minutes. What is the hourly rate?
200ml/hr
Name the different 5 types of Debridement
What is Enzymatic Debridement, Autolytic Debridement, Sharp/Surgical Debridement Mechanical Debridement, and Chemical Debridement
A client with anemia has an SpO₂ reading of 98% but the nurse is concerned. Why might the SpO₂ reading not reflect adequate oxygen delivery to tissues?
Because there may be insufficient hemoglobin to carry oxygen despite saturation
What are examples of Active and Passive Drains and what is their purpose?
Active Drains- Hemovac, Jackson-Pratt
Passive drain- Penrose drain
Permits drainage of excessive exudate or fluid buildup
Name at least 3 indication for trach suctioning.
Noisy breathing
bubbling of mucus
moist cough/respirations
signs of hypoxia
0.4 L of D5W in Normal Saline to infuse over 3 hours." Drip factor: 10 gtt/mL. What will you set the drip rate to?
22 gtt/min
List at least 5 Risk Factors for Developing a Pressure Ulcer
•Pressure
•Friction/Shearing
•Immobility/ Inactivity
•Inadequate nutrition & dehydration
•Weight loss, muscle atrophy, loss of sub-Q tissue
•Hypoproteinemia→ Edema
•Moisture/Incontinence (fecal or urinary)
•Obesity
•Edema
•Decreased mental status
•Diminished sensation (paralysis, stroke)
•Excessive body heat
•Advanced age
•Chronic medical conditions