Infection/ Wounds
What puts patients most at risk for infection
post surgical
diabetes
chronic alcoholism
Proper technique for removing a PICC line
flat supine or Trendelenburg
do not pull or force if resistance is felt!
What indicates patient is experiencing an allergic reaction to blood?
a. Generalized itching.
b. Development of oral thrush.
c. An increase in pulse (P) from 64 to 72.
d. An increase in systolic blood pressure (SBP) from 100 to 150 mm Hg.
generalized itching
TB patient should be on what precaution?
Airborne
N95
negative pressure room
Best way to make sure a patient knows how to properly handle drain care when being discharged with a drain?
Have patient demonstrate safe handling versus having them verbally explain steps
Teach back vs written instructions
Patient receiving total parenteral nutrition (TPN) therapy. What provides the nurse with information regarding the nutritional status of the client?
Prealbumin level
Cane proper technique
Hold with stronger arm
move cane and affected leg together
move cane + weaker leg and then move stronger leg
Packed red blood cells are given to which patients
anemic patients
MRSA Teaching
Contact precautions
no bathing!
Launder washcloth/ towel after using once
Change dressings promptly with drainage
clean with high potency cleaning solutions not soap and water
Dehesinence findings: SATA
1. Crusting around the incision line.
2. Purulent drainage from the incision site.
3. Slight swelling under the incisional staples.
4. An increase in incisional drainage amount.
5. A change in drainage from serous to
serosanguinous.
2. Purulent drainage from the incision site.
4. An increase in incisional drainage amount.
5. A change in drainage from serous to
serosanguinous.
TPN was supposed to be delivered 30 minutes ago, what should the nurse hang in its place until it is delivered?
Hang 10% dextrose in water until the TPN solution is delivered.
Safe patient handing for nurses
Keep body as close to patient as possible when providing care (dont lean over or bend)
keep at working level (dont keep bed at lowest position)
keep feet in wide stance hip apart
stand in front of patient when helping them stand
Shift hand off report:
Patient is 0 negative and has 30 minutes left of blood. New nurse walks in and sees 0 + is being given. What should she do?
a. Take the client’s vital signs (VS).
b. Make sure blood is scheduled to finish in 30 minutes.
c. Notify the blood bank.
d. Stop the infusion.
STOP infusion!
The nurse is caring for a client who is unconscious and requires emergency surgery. The client is unable to give consent. What should the nurse do?
a. Contact the medical POA by phone and obtain verbal consent for the procedure.
b. Proceed with surgery and have the client sign the consent after the procedure.
c. Obtain consent from the client’s friend who brought the client to the hospital.
d. Obtain in writing by the primary health care provider (PHCP) that the surgery is medically necessary
Contact the medical POA by phone and obtain verbal consent for the procedure.
The client has developed a low-grade temperature and purulent drainage from the surgical wound.
Which of the following actions is the priority for the nurse to take?
a. Reassess the client’s temperature.
b. Obtain wound culture and sensitivity (C&S).
c. Administer the prescribed antibiotic.
d. Administer acetaminophen for temperature.
Wound culture and sensitivity
The nurse is caring for a client who is receiving morphine via an epidural catheter for the treatment of chronic pain relief. Which of the following actions should the nurse be prepared to take when caring for the client?
a. Notify the primary health care provider (PHCP) if the client develops a severe headache.
b. Obtain a prescription for flumazenil if the client develops respiratory depression.
c. Expect that the client will be difficult to arouse when nailbed pressure is applied.
d. Assess the client’s blood pressure for hypertension and pulse for tachycardia.
Notify the primary health care provider (PHCP) if the client develops a severe headache.
Cellulitis findings SATA
1. Raised vesicles.
2. Erythema.
3. Itching.
4. Enlarged lymph nodes.
5. Warmth.
6. Burning.
7. Fever.
erythema
enlarged lymph nodes
warmth
fever
B12 Anemia finding
Beefy red tongue
Priority lab finding to report to surgeon presurgical
a. Hemoglobin (Hgb), 9.6 mg/dL.
b. White blood cell count (WBC), 8.5 mm³.
c. Prothrombin time (PT), 11 seconds.
d. Blood urea nitrogen (BUN), 10 mg/dL.
Hgb (less than 12 and anemic less than 10)
All others are WNL
The nurse is assessing a client who has been diagnosed with herpes zoster. Which of the following
should the nurse expect to find in this client?
a. Tender nodules.
b. Elevated patches.
c. Small, red macules.
d. Painful vesicles.
painful vesicles
Priority before giving TPN or administering medication through a line
verify placement!
X Ray at bedside and then mark placement for future assessments
flush before and after
make sure medications can be crushed
what are we doing to prevent skin break down
do not rub reddened areas
no donut pillows
position the legs to float the heels
keep skin dry and clean
assess skin every 2 hours
Sickle Cell Crisis Interventions
FLUIDS!
Pain control!
remove restrive clothing
avoid BP cuff
keep room above 72
It is correct for the nurse to state
that
a. “A surgical gown should be applied when entering the room of a client who has bacterial
pneumonia.”
b. “Disposable utensils must be provided for a client infected with hepatitis virus C (HVC).”
c. “A surgical mask should be worn when working within 3 feet of a client infected with Neisseria meningitidis.”
d. “The nurse should wear a surgical mask when transporting a client who has active pulmonary
tuberculosis (TB).”
“A surgical mask should be worn when working within 3 feet of a client infected with Neisseria meningitidis.”