IV Therapy
Where is the IV drop factor located?
IV tubing package
How does the nurse verify placement of an enteral tube?
Initial placement: x-ray
Additional access: external measurement and PH
What order do you perform an abdominal assessment? Why?
Inspect, Auscultate, Percuss, Palpate
What does RITTA stand for? What is it used to assess?
Redness, Induration, Temperature, Tenderness, Approximation.
Used to assess Periwound
What would indicate a positive finding for a occult blood stool test?
Blue discoloration
This is the priority prior to hanging and IVPB.
Checking IV compatibility
These types of medications cannot be put through an enteral tube.
Bulk forming and "Do Not Crush" medications
The nurse notices an area of redness on a patients skin. What is the first thing the nurse should do?
Assess for blanchability and reposition patient.
Name and describe the 4 types of drainage.
Serous- yellow, clear, watery
Serosanguineous- Pink, blood-tinged
Sanguineous- Bloody, red
Purulent- thick, creamy, yellow/green, odorous
What should a healthy stoma look like?
Raise, pink/red, moist
Name 3 things assessed on an IV site.
Redness, swelling, drainage, dressing is CDI, pain/tenderness, temperature.
Nausea, distension, cramping, diarrhea caused by too much in the small intestines at one time. Patients with intestinal tubes most at risk.
What is paronychia?
A tender infection or inflammation around the base of the nail fold.
What does the Red, Yellow, Black wound classification describe and what does each color mean?
Wound Bed
Red- Granulation Tissue
Yellow- Slough
Black- Necrotic
When inserting an indwelling urinary catheter into a female client you see a flash a urine, what do you do next? What if this was a male client?
Female- insert another 2-3 inches and inflate the balloon.
Male- insert until the bifurcation and inflate the balloon.
Describe the process of priming secondary tubing.
Check IV compatibility, close the roller clamp, spike the IVPB bag, clean the y-site closest to the primary bag, clamp the primary roller clamp, keep the IVPB bag lower than primary bag, open roller clamp and backfill secondary drip chamber to half full.
Describe the steps to removing an NG tube?
•Complete abdominal assessment
•Have patient sitting upright
•Check placement
•Instill 30-50 mL of air to clear tubing prior to removal
•Instruct patient to hold their breath
•Remove and coil in hand
What are the 4 different abdominal contours?
Scaphoid (Concave/ Sunken in)
Flat
Round
Protuberant
What all needs to be documented for a wound assessment?
Location, Type of wound, Wound bed (undermining/tunneling), Measurements, Peri-wound skin, wound closure (count if applicable), drainage, Pain, Dressings
What is the difference between Isotonic, hypotonic and hypertonic enemas? Give an example of each.
Hypotonic- (tap water enema) large volume, solution warmed, given over 5-10 mins
Isotonic- (saline enema) large volume, solution warmed, given over 5-10 mins
Hypertonic- (fleets) small volume, draws water into colon, given at room temperature, given over 1-2 mins
Signs and symptoms may include an increase in blood pressure, abnormal heart and lung sounds, change in Level of consciousness, engorged neck veins and dyspnea. What is this complication and what should the nurse do next?
Fluid Overload
Raise the HOB, stop infusion and contact provider.
What signs and symptoms would indicate a enteral tube placed for decompression was not working.
Decreased output, nausea, vomiting, pain, distension.
What does ABCDE stand for and what is it used to assess?
Used to assess lesions.
A for Asymmetry of pigmented lesions
B is Border Irregularity
C for Color Variation
D for diameter greater than 6 mm
And E is for elevation or evolution.
Describe pressure injury staging and what each stage means.
•Stage 1 pressure injuries are intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred. Nonblanchable erythema is a medical term used to describe skin redness that does not turn white when pressed.
•Stage 2 pressure injuries are partial-thickness loss of skin with exposed dermis. The wound bed is visable and may appear like an intact or ruptured blister.
•Stage 3 pressure injuries are full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. The depth of tissue damage varies by anatomical location.
•Stage 4 pressure injuries are full-thickness tissue loss like Stage 3 pressure injuries, but also have exposed cartilage, tendon, ligament, muscle, or bone.
Describe the steps to collecting a sterile urine specimen from a catheter and the rationale?
Clamp the catheter tubing just below the self-sealing port for 10-15 minutes to collect ‘fresh’ urine
b. Cleanse the self sealing port with alcohol for 15-30 seconds.
c. Insert the syringe onto the self sealing port and withdraw 10mL of urine. Sterilely transfer to sterile
specimen container. Label container and place in biohazard bag.
d. Unclamp the catheter tubing
To ensure that a sample of urine is taken from the bladder and not the urine bag