Medication Administration
A student nurse is administering meds to a client through a G-tube. Which of the following actions requires the clinical instructor to intervene? A.) The student places all meds in different medicine cups, B.) The student evaluates each med and holds the feeding before administering a med that needs to be given on an empty stomach, C.) The student flushes the tube with 30 mL of water between each med, D.) The student crushes Nifedipine extended-release and mixes with water before administering.
What is: D.) The student crushes Nifedipine extended-release and mixes with water before administering.
Review the steps of performing tracheostomy care
Sterile procedure done every 8 hours when client is stable. Dispose of gauze. If inner cannula is disposable, throw away and obtain new one. If the inner cannula is not disposible, clean it with saline and brush. Clean stoma and top of faceplate. Place new gauze. Keep old ties on while placing new trach ties. Then remove old ties.
What are the nutrition needs for toddlers, adolescence, pregnancy, and older adults?
toddler- picky eaters. limit milk to 24 oz daily
adolescent- ensure diet is balanced: protein, calcium, iron
pregnancy- increase folic acid and iron
older adult- decreased need food energy due to slowing of metabolism
Review principles of crutch usage
2 point gait- opposite crutch and opposite leg move simultaneously
3 point gait- both crutches move simultaneously forward. Then the unaffected leg hops forward
4 point gait- opposite foot and opposite crutch move one point at a time
2-3 fingerbreaths space from axilla to top of crutch.
When usins crutches on the stairs, the good leg goes up first (good to heaven). The affected leg and the crutch go down first (bad leg goes to hell)
A nurse is planning care for a client that has AIDS. The nurse knows to wear gloves under which of the following circumstances? (Select-all-that-apply): A.) When cleaning an open wound, B.) During all contact with the client, C.) When starting an IV catheter, D.) When drawing blood
What is: A.) When the client has an open wound, C.) When starting an IV catheter, D.) When drawing blood
What are appropriate patient identifiers?
Full name & date of birth or full name and medical record number
How is a medication in a dry powder inhaler administered?
deep inhalation and good force needed. BREATH-DOSE COORDINATION NOT NEEDED.
BONUS- how is a pressurized meter dose inhaler administered?
what items should be at the trach client's bedside for airway safety?
two spare tracheostomies (One same size and one size down), ambu bag, sterile saline, obturator, trash care kit, trash suction kits
What is a medication reconciliation?
nurses, pharmacists, and other healthcare providers compare medications patient is taking currently with what the patient should be taking and any newly ordered medications
The RN is performing a nutrition assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (Select-all-that-apply): A.) Poor wound healing, B.) Brittle, dry hair, C.) BP 130/80, D.) Weak hand grips, E.) Impaired gait and coordination
What is: A.) Poor wound healing, B.) Brittle, dry hair, D.) Weak hand grips, E.) Impaired gait and coordination
After receiving an IM injection in the deltoid the client states, "My arm really hurts. It's burning and tingling where I got my injection". What should the nurse do next? (Select-all-that-apply): A.) Assess the injection site, B.) Administer an oral med for pain, C.) Notify the HC provider of assessment findings, D.) Document the findings and interventions in the EHR, E.) This is a normal finding, so nothing needs to be done, F.) Apply ice to the site to relieve the burning.
What is: A.) Assess the injection site, C.) Notify the HC provider of assessment findings &D.) Document the findings and interventions in the EHR
The nurse assesses a new client and finds the client is short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? Chose one answer A.) Raise the HOB to 90 B.) Get the O2 sat with the pulse oximeter, C.) Take the BP and RR, D.) Notify the HC provider of the SOB
What is: A.) Raise the HOB to 45 degrees or higher
What is the order of Donning and Doffing PPE?
Don- gown, mask, goggles, gloves
Doff- gloves, goggles, gown, mask
List the sites, angle, technique, needle gauge and lengths for: IM, Subcut, and ID injections
IM-21-23g 1/2-5/8 inch needle. z track (displace) & aspirate for non-immunizations. deltoid, ventrogluteal, vastus lateralis
Sucut-25-31g 1/4-5/8inch. posterior outer arm apect, abdomen, anterior thigh. 45-90 degree. Pinch
ID-25-27g 1/2-5/8inch. Forearm/back. 5-15 angle, displace skin.
All: Poke fast, push slow. Don't massage after administration
Review principles of sterility
sterile only touches sterile, one inch border is not sterile, lip sterile water bottle that has been opened. palm to label of sterile water bottle, sterile items above waist, don't turn back to sterile field, sterile field that becomes wet is contaminated. don't reach over the sterile field. Open package: away (outer), side, side, closest.
Bonus- what are sterile skills? give examples
A nurse prepares an injection of Morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another client needs to use a bedpan. Which of the following actions should the second nurse take? A.) Offer to assist the client who needs to use the bedpan, B.) Administer the injection to the first client, C.) Prepare another syring to administer the injection or D.) Tell the client who needs the bedpan to wait while the first nurse gives the injection
What is: A.) Offer to assist the client who needs to use the bedpan
Which of the following skills can the RN delegate to the assistive personnel? (Select-all-that-apply): A.) Naso-tracheal suctioning, B.) Oropharyngeal suctioning of a stable client, C.) Suctioning a new artificial airway, D.)Care of an endotracheal tube
What is: B.) Oropharyngeal suctioning of a stable client
A nurse is preparing to teach about range of motion exercises. What is range of motion exercise and why is it performed?
maintain joint flexibility in immobile client. Passive range of motion is done by the RN. Active ROM is done by the client. should be done 3-4 times per day on mobile clients to prevent contractures. evaluate the response to exercise
what clients should be placed on restraints?
restraints are the last option used once all alternatives have been exhausted. Used on clients that are a harm to themselves or others. May possibly be used on a client purposefully ripping out foley, IV, NG. RN should assess device to ensure there is no complication and functioning appropriately first
A triage nurse is reviewing messages from 4 clients. Which client is the nurses' priority? A.) Adult male with cloudy urine and fever of 38.6 F/101.4F, B.) Adult female with pain in the jaw and back pain that has become more intense in the past 15 minutes, C.) Adult female with hot flashes and irritability to sleep for the past 4 nights, D.) Older adult male with a closed fracture of the tibia who rates his pain level as 7/10
What is: B.) Adult female with pain in the jaw and back pain that has become more intense in the past 15 minutes
Describe eye drop medication administration process
Have client tip head back and look up, don't touch the tip of the dropper, wear gloves, administered prescribed number of drops into the conjunctival sac
A client has a tracheostomy. How would the RN know the client requires suctioning?
The client has crackles and/or has low SP02.
Bonus: review steps of tracheostomy suctioning
Describe proper body mechanics
Feet shoulder-width apart, bend with knees (not back), don't reach over bed, face direction of movement, keep center of gravity low, place items close to your body
How are medicated patches placed on client?
Wear gloves. Check client to ensure prior patch has been removed. If order does not specify patch location, choose area free of hair, sessions, irritation. Typically the trunk area is used. Clean skin with soap and water. Dry and place patch. date, time and initial patch. Document on the MAR body location of application. Alternate patch locations
What interventions can be done to help prevent nasal dryness from supplemental oxygen?
water-based ointment or saline spray can be used. Also, get order for humidified oxygen. Don't use petroleum jelly. It is flammable.