Arterial Lines
96 hours (4 days)
What emergency supplies are good to keep at the bedside for my patient that has a chest tube?
Blue clamps, gauze, Vaseline gauze and 3" foam tape.
My patient's NG is being discontinued. Who is allowed remove the patient's bridle in order to d/c the NG?
Any licensed RN/LPN (aka we do) :)
You discontinued your patient's foley 6 hours ago. They state that they don't currently have an urge to urinate. Are you concerned and what's your next move?
You should be concerned for potential urinary retention. Bladder scan the patient and call the physician, if required.
You have an order to drain precisely 10 ml Q1H from this drain. What type of drain is this?
Lumbar drain
Where should the arterial line be leveled at to ensure optimal values?
Phelbostatic Axis
If my patient's chest tube invertedly becomes knocked over, what is my next step?
Set up another chest tube drainage system. Clamp only long enough to swap the tubing to the new system and utilize the quick release to swap the atrium over.
Check length Q4 hours and document (number/mark placement). We should check gastric pH Q12hr (usually at 6/6) after allowing the feeds to be paused for a minimum of 10 minutes.
You are about to travel to MRI with your patient who has a foley. What's something you need to ensure you do prior to traveling?
Empty the bag
You have noticed a significant drop off in csf drainage from your EVD. What's next?
Lower the level of the drain to verify patency. If no output, call neurosurgery immediately.
Upon discontinuing my patients arterial line, how long must I hold pressure and for how long must a pressure dressing remain in place?
5-minute pressure hold and 4-hour (minimum) pressure dressing.
My patient's chest tube became disconnected during a turn and I witnessed it happen. What do I do?
Clamp the tubing immediately, clean the connection with alcohol and reconnect.
My patient is 2 weeks post-op from a low-profile gastrostomy tube placement, and he accidentally pulled the g tube out. What are my next steps?
Since under 6 weeks, we should immediately collect back up kit and glide the new g tube in the stoma utilizing lubricant (do not inflate the balloon) and put foam tape over site. Call peds surgery to assess and do not utilize in meantime.
Your physician placed an order for a UA with reflex to culture. What is the most pertinent question you should be asking yourself?
How long has my foley been in?
True or false...you will always apply suction to a Jackson Pratt bulb drain
False. Always reference your order to see if the provider wants the patient to receive suction or drainage therapy
I just admitted my post-op patient and their arterial line has no securement. What should my next step be?
Call the provider for guidance on if it should be added (must consider how long it will be in place, how active the patient is, etc.). If clinically indicated, decide who is the best person to add (provider if sutured, ANM or RR/UC if stat lock being added).
My patient's chest tube is ordered to suction, but we must travel to CT. What must I do to accomplish this?
Depending on the patient scenario, it may be appropriate to ask physician to provide an order to go to water seal for travel. If not appropriate, then you must travel with portable suction.
I just finished my med pass that included G and J tube medications. How exactly should I flush my J tube before clamping?
J tube's must be flushed with 10 mL via a 35cc or larger syringe.
Name three causes of a leaking foley and provide the resource for troubleshooting other potential causes.
Mechanical problems, blader is overly full, bladder spasm, constipation, uti, wrong size catheter, balloon does not have proper volume within.
Leaking foley algorithm
Your patient has an Oasis dry suction set up in their room but in report, you don't receive any information about the need for a chest tube. What question should you ask?
Is this a pericardial drain?
My patient's arterial line is having issues with bleeding and QuickClot is currently in place. How long is this good for before a transition back to Stat Seal occurs?
24 hours.
Please place our patients chest tube to water seal
RN places chest tube to water seal correctly :)
Please hook up a Farell valve to this patients g tube.
RN accurately hooks up Farrell valve to g tube.
Ensure the patient's foley is compliant with our CAUTI bundle elements
No dependent loops, bag is <2/3 full, daily need assessed, bag is below bladder, stat lock is appropriately positioned
The EVD bag is >3/4 full at shift change. Please help the off-going nurse change this bag.
Shows process for changing out the EVD bag