Meds
What interventions should the nurse be doing after the administration of opioids?
Assess respirations, pulse ox, protect airway.
What is the formula for finding drip rate and flow rate?
mL mL
____ X drip factor _____
min HR
What are some ways to prevent pressure injuries?
1. Pay attention to bony prominence
2. avoid massage over bony prominence
3. Use proper positioning, turning and transferring techniques
4. Turn patients every 2 hours
What is fluid overload?
Too large a volume of fluid infused into circulation.
What is the priority nursing assessment immediately post-operatively?
Airway Patency
What are side effects of metformin?
Lactic acidosis, abdominal bloating, nausea, vomiting, diarrhea.
Hydralazine 1mg is ordered for the pt. Available is 0.2mg tablets. How many tablets will be administered?
5 tablets
How do you clean a wound with approximated edges?
1. Use standard precautions
2. Moisten a sterile gauze pad or swab
3. Use a new swab or gauze for each downward stroke
4. clean from top to bottom
5. Work outward from the incision in parallel to it
6. Wipe from the clean area toward the less clean area.
What would be signs and symptoms of a venous access device related infection?
Erythema, edema, drainage at the insertion site, fever, malaise, chills and other vital sign changes.
If a patient is having severe pain secondary to a tibial fracture that is unrelieved by opioid analgesics, what operation can the nurse expect to prepare the patient for?
Fasciotomy
How do you mix insulin?
Inject air into humulin N, inject air into humulin R, keep in and pull back from R, and then pull back from N. NRRN
Pt is ordered bolus of 500mL over 6 hours. Calculate flow rate, round as appropriate.
83.3mL/hr
What is used to clean a wound?
Saline with no preservatives
What are signs and symptoms of fluid overload?
Engorged neck veins, increased blood pressure, dyspnea.
Your patient is ordered 25 mg of Spironolactone for hypertension. Her morning vitals were: HR 92, Temp 36.5, BP 142/88, RR 16, SpO2 95%. Before administering, you see that her serum potassium level is 5.6 mEq/L. What is your next course of action?
Hold the medication and contact the physician to determine how to proceed
What are side effects of Heparin?
bleeding, HIT, anemia, osteoporosis, hyperkalemia
Pt is ordered 450mL packed red blood cells to infuse over 6 hours. Drip factor 20gtt/min. Calculate the flow rate for one unit.
25 gtt/min
What is your next action if you go to take a swab of the wound and realize it has not been cleaned and why?
Discard the swab and get a new one because it would lead to inaccurate results.
What would be some nursing considerations when dealing with Speed shock?
Make sure you are using proper IV tubing, Carefully monitor the rate of fluid flow, Check the rate frequency for accuracy, Time tape would also be useful.
What are 4 lifestyle modifications that should be explored with a patient with primary hypertension?
1. diet modifications - restrict sodium, cholesterol, and saturated fat; increase fruits, vegetables, and fish
2. daily moderate to intense exercise for at least 30 minutes
3. smoking cessation
4. moderation or cessation of alcohol intake
What is the onset and duration of insulin aspart?
Type of rapid acting insulin.
Onset: within 15 minutes
Peak: 1-2 hr
Duration: 3-4 hr
Pt is ordered lanoxin 2mg/kg q12hr. What is the desired dose if the pt weighs 120lbs?
109.1 mg
What needs to be documented after wound care?
Location of wound, assessment of wound, type of tissue present, stage, characteristics of drainage, appearance of surrounding skin, cleansing and culture of wound, skin care or dressings applied
What are 4 thing that you could do as a nurse if fluid does not flow easily into the vein?
1. Reposition the extremity
2. Raise the height of the pole
3. Attempt to flush the PIVC with saline
4. Make sure the clamp is fully open
BP 98/60 mm Hg, HR 102 bpm, RR 24, temp 36.7, and SpO2 84% on 2 L/min via nasal cannula
Which of these findings is the highest priority and what would the nurse do next?
SpO2 84% is the highest priority
Place the patient in high fowlers, auscultate breath sounds, assess LOC, check oxygen connection and rate setting, and talk with the patient about their breathing