Trach Care
Crystalloids vs Colloids
Assessment Findings
Math! Math! Math!
Moms and Babies
100
A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first?
A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
C
Assessment is the first phase of the nursing process. All other actions and procedures are driven by assessment findings. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs.
100
A patient who needs a unit of packed red blood cells is ordered by the physician to be premeditated with oral diphenhydramine and acetaminophen. You will administer these medications?*
- A. 15 minutes before starting the transfusion
- B. Immediately after starting the transfusion
- C. Right before starting the transfusion
- D. 30 minutes before starting the transfusion
The answer is D.
For ORAL medications you will administer the medications 30 minutes before starting the transfusion.
100
A patient with TPN infusing has disconnected the tubing from the central line catheter. The nurse assesses the patient and suspects an air embolism. The nurse should immediately place the patient in which position?
A. On the left side, with the head lower than the feet
B. On the left side, with the head higher than the feet
C. On the right side, with the head higher than the feet
D. On the right side, with the head higher than the feet
A. on the left side, with the head lower than the feet
100
Doctor's order says: "Infuse 1500 mL of Lactated Ringer's over 12 hours." Drip factor: 15 gtt/mL*
- A. 31 gtt/min
- B. 32 gtt/min
- C. 95 gtt/min
- D. 15 gtt/min
Doctor's order says: "Infuse 1500 mL of Lactated Ringer's over 12 hours." Drip factor: 15 gtt/mL
- A. 31 gtt/min
The answer is A.
100
What is the expected delivery date of a patient whose conception is reported on June 20, 2012?
A. March 13, 2013
B. March 27, 2013
C. February 13, 2013
D. February 27, 2013
B
(The gestation period of a fetus is 266 days from the date of conception and 280 days from the last menstrual period. Calculating the gestational period after conception from June 20, the expected date of delivery is March 13, 2013. March 27, 2013, is the expected date of delivery if June 20, 2012, is the first day of the last menstrual period. February 13 and 27 are not the expected date of delivery unless the baby is a preterm infant.)
200
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? SELECT ALL THAT APPLY.
A. Encourage frequent sipping from a cup
B. Encourage water with meals
C. Inflate the tracheostomy cuff during meals
D. Maintain the client upright for 30 minutes after eating
E. Provide small, frequent meals
F. Teach the client to "tuck" the chin down in the forward position to swallow
DEF
At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration.
Eating requires significant time and energy. When the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration.
Tucking the chin downward helps to open the upper esophageal sphincter.
200
Maintenance care of a peripheral intravenous site includes: (List 4)
Changing IV fluids
Changing the IV dressing
Changing IV tubing
Ongoing assessment
200
A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse notes that the hourly drainage is less than the amount of the irrigation being given. Which actions by the nurse would be most appropriate? (List 2)
Palpate the client's bladder for distention,
Check the tubing for any kinking
200
Doctor's order says: "Two 250 mL Packed Red Blood Cells to infuse over 4 hours." Drip factor: 15 gtt/mL*
- A. 31 gtt/min
- B. 19 gtt/min
- C. 30 gtt/min
- D. 32 gtt/min
Doctor's order says: "Two 250 mL Packed Red Blood Cells to infuse over 4 hours." Drip factor: 15 gtt/mL
- A. 31 gtt/min
The answer is A. NOTE: It says TWO bags of RBC....which equals 500 mL...not 250 mL.
200
The nurse receives an order to start an infusion for a client whos hemorrhaging due to a placenta previa. What supplies will be needed?
1. Y tubing, normal saline solution, and 20G cathether
2. Ytubing, lactated Ringers solution and 18G cath
3. Y tubing, normal saline, 18G cath
4. Y tubing, lactated RIngers, 20G cath
3. Y tubing, normal saline, 18G cath
blood transfusions require
Y tubing
Normal Saline solution
to mix with the blood product and an 18G cath to avoid lysing breaking the RBCs.
A 20G cath lumen isnt large enough for a blood transfusion.
Lactated RIngers solutions isnt the IV solution of choice for blood transfusions
300
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
A. Auscultate the client's breath sounds while applying a nasal cannula
B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask
C. Apply a 100% non-rebreather mask while administering high-flow oxygen
D. Replace the obturator while inserting the tracheostomy tube
B
Because a fresh tracheostomy stoma will collapse, the client will lose his airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to re-cannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.
300
A patient is receiving 1 unit of packed red blood cells. The unit of blood will be done at 1200. The patient is scheduled to have IV antibiotics at 1000. As the nurse you will:*
- A. Stop the blood transfusion and administer the IV antibiotic, and when the antibiotic is done resume the blood transfusion.
- B. Administer the IV antibiotic via secondary tubing into the blood transfusion’s y-tubing.
- C. Hold the antibiotic until the blood transfusion is done.
- D. Administer the IV antibiotic as scheduled in a second IV access site.
The answer is D.
If any IV medications will be needed while the blood is transfusing, the nurse will need to start another IV access site. The nurse would NEVER administer the IV antibiotic in the same tubing as the blood product or stop the transfusion. Remember blood is time sensitive and must be transfused within 4 hours. Also, holding the antibiotic is not correct because antibiotics are time sensitive as well and must be administered at the scheduled time to maintain blood levels.
300
True or False:
A chest x-ray is always used to confirm the placement of all central lines. True or False.
True
300
Doctor's order says: "650 mL of D5W to infuse over 6 hours." Drip factor: 10 gtt/mL*
- A. 360 gtt/min
- B. 96 gtt/min
- C. 9 gtt/min
- D. 18 gtt/min
D. 18 gtt/min
The answer is D.
300
The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygen needs aren't being met?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis
C
Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.
400
A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication?
A-Explain to the client that speech will be clear and distinct with a fenestrated tube.
B-Reassure the client that in time he or she will get used to the speech difficulties.
C-Place a sign above the client's bed indicating that the client cannot s peak.
D-Provide the client with a communication board and call light within easy reach.
The answer is: D
400
How are colloid solutions different from crystalloid solutions? Select all the differences below:(Required)
A. Colloid solutions require a high amount of fluid administration to equal the actual amount lost.
B. Colloid solutions cost more and are not as easily accessible as crystalloid solutions.
C. An example of a colloid solution is 3% saline, while an example of a crystalloid solution is 0.9% normal saline.
D. Colloid solutions contain large molecules that stay in the intravascular space longer than crystalloid solutions.
E. Allergic reactions and coagulation problems are not associated with the use of crystalloid solutions but are associated with colloid solutions.
The answers are B, D, and E. These are correct statements about colloids vs. crystalloid solutions. Options A and C are incorrect.
B. Colloid solutions cost more and are not as easily accessible as crystalloid solutions.
D. Colloid solutions contain large molecules that stay in the intravascular space longer than crystalloid solutions.
E. Allergic reactions and coagulation problems are not associated with the use of crystalloid solutions but are associated with colloid solutions.
400
The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must:
A. Keep splashes on the sterile field to a minimum.
B. Cover the nose and mouth with gloved hands if a sneeze is imminent.
C. Use forceps soaked in a disinfectant.
D. Consider the outer 1 inch of the sterile field as contaminated.
D. Consider the outer 1 inch of the sterile fielda s contaminated
400
The doctor writes an order to infuse a solution. The order reads: "Infuse 500 mL bag at 20 gtt/min". The drip factor is 10 gtt/mL. You start the IV infusion at 0500. At what time will the infusion be complete?*
- A. 0630
- B. 0853
- C. 2210
- D. 0910
D. 0910
The answer is D.
400
On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following.
A. Call the physician
B. Assess the client's vital signs
C. Gently massage the uterine fundus
D. Administer a 300ml bolus of a 20 units/L Oxytocin(Pitocin) solution
C.
The most frequent cause of excessive bleeding or hemorrhage after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options A, B and D may be necessary eventually but are not initial actions. The initial action is to alleviate the problem.
500
The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving?
A-24%
B-28%
C-36%
D-40%
The answer is: D
500
As the nurse you know that there is a risk of a transfusion reaction during the administration of red blood cells. Which patient below it is at most RISK for a febrile (non-hemolytic) transfusion reaction?*
- A. A 38 year old male who has received multiple blood transfusions in the past year.
- B. A 42 year old female who is immunocompromised.
- C. A 78 year old male who is B+ that just received AB+ blood during a transfusion.
- D. A 25 year old female who is AB+ and just received B+ blood.
The answer is A.
A febrile transfusion reaction is where the recipient’s WBCs are reacting with the donor’s WBCs. This causes the body to build antibodies. It is most COMMON in patients who have received blood transfusion in the past. Option B is at risk for GvHD (graft versus host disease). Option C is wrong because this places the patient at risk for a hemolytic transfusion reaction (not febrile). The patient is receiving incompatible blood. However, option D is not the patient at MOST risk compared to option A. Note the patient is receiving compatible blood. Note the patient is receiving compatible blood in this option.
500
A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.)
1) palpating the bladder height.
2) obtaining a clean-catch urine specimen.
3) performing a bladder scan.
4) asking the patient about his recent voiding history.
5) encouraging the patient to consume cranberry juice daily.
6) inserting a straight catheter to measure residual urine.
Answer:
1) Palpating the bladder height.
3) Performing a bladder scan.
4) Asking the patient about his recent voiding history.
Rationale:
The nurse should palpate the bladder for distention.
A bladder scan will yield a more accurate measurement of the postvoid residual urine. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care.
A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection.
Cranberry juice is sometimes used to in an effort to prevent urinary tract infection, although there is conflicting research to support this action.
Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder and is usually unnecessary if the nurse has access to a portable bladder scanner.
500
A health care provider prescribes 1,500 mL of normal saline to be infused over seven (7) hours. The drop factor is 15 drops/mL. The nurse should set the flow rate of the IV infusion pump at how many mL per hour (mL/hour) and drops per minute (drops/minute)?
This question requires you to compute for two answers. Fill in the blanks and round your final answers to a whole number.
Answer: _____mL/hour or ______ drops/minute
Correct answers:
- 214 mL/hour
- 54 drops/minute
Formula
mL/h=total infusion volume(mL)total infusion time(h)mL/h=total infusion time(h)total infusion volume(mL)
Solving for the mL per hour (mL/hour)
- Use the IV flow rate formula (mL/hour) above.
- Divide 1,500 mL (total infusion volume) with 7 hours (total infusion time) to get 214.28 mL.
- Round off your final answer to get 214 mL/hour.
1,500ml7hours=214.3mL/hour7hours1,500ml=214.3mL/hour
Solving for the drops per minute (drops/minute)
- Use the IV flow rate formula above.
- Convert 7 hours to minutes by multiplying 7 hours to 60 minutes per hour and get 420 minutes.
- Divide 1,500 mL (total infusion volume) by 420 minutes (total infusion time) to get 3.57 mL/minute.
- Multiply 3.57 mL/minute to the drop factor of 15 drops/mL to get 53.55 drops per mL.
- Round up your final answer to get 54 drops per minute.
1,500ml420minutesX15dropsmL=53.55drops/minute420minutes1,500mlXmL15drops=53.55drops/minute
500
Which assessment is least likely to be associated with a breech presentation?
a. Meconium-stained amniotic fluid
b. Fetal heart tones heard at or above the maternal umbilicus
c. Preterm labor and birth
d. Post-term gestation
D
Post-term gestation is not likely to be seen with a breech presentation. The presence of meconium in a breech presentation may result from pressure on the fetal wall as it traverses the birth canal. Fetal heart tones heard at the level of the umbilical level of the mother are a typical finding in a breech presentation because the fetal back would be located in the upper abdominal area. Breech presentations often occur in preterm births.