4335 Quiz 1-4
List 4 complications that can arise from a peripheral IV Phlebitis Infiltration Air embolism Extravasation
1. Phlebitis, which is an inflammation of the inner layer of a vein. This occurs when the cannula used is too large for the vein or if the cannula is improperly secured. 2. Infiltration is when the IV fluid enters the subcutaneous tissue surrounding the vein and extravasation is when a vesicant or tissue-damaging drug (e.g. chemotherapy) enters the tissue. 3. Air embolism occurs when an air bubble or air bubbles enters the vein, which can be fatal if not caught early as the air can enter a person's brain, heart, or lungs. 4. Local infection can occur if the IV line, port, or the skin surrounding the vein are not properly cleaned prior to infusion or after removal of the IV catheter.
The doctor writes an order to infuse a solution. The order reads: "Infuse 2,500 mLover 1 day.". What is the hourly rate (mL/hr)? Round to the nearest whole number.
104 mL/hr 2,500 / 24 = 104 mL/hr
At 0900, the nurse hangs an IV of 1000 mL D5LR to infuse at 83 mL/hr. What time will the nurse need to hang a new bag of IV fluid. Provide your answer in military time.
2100 hours 1000mL / 83mL = 12 ; 0900+ 12= 2100
A nurse is teaching a new nurse how to remove a midline catheter. The nurse asks the new nurse what the minimum amount of time is to hold pressure on the site after the catheter is removed. Which of the following responses would indicate the new nurse understood the teaching?
30 seconds Applying pressure for 30 seconds is an adequate amount of time for clotting to occur and stop bleeding. Pressure should be held longer in patients taken anti-coagulants or anti-platelets.
Based on knowledge of areas at greatest risk for development of a pressure ulcer in a bedridden patient, the nurse identifies which position to minimize the risk?
30-degree side lying This position puts the least amount of pressure on bony prominences. The others will increase pressure in at risk areas for a pressure ulcer to form.
Doctor orders Zithromax for a child that weighs 82 lbs. The safe dose range for this medication is 10-12 mg/kg/day. What is the maximum safe daily dose for this child?
447.3 mg/dose 82 / 2.2 =37.27 37.27 x 12 = 447.24, rounded to the nearest tenth = 447.3 mg
The doctor writes an order to infuse a solution. The order reads: "Infuse 1500 mL over 12 hours". The drip factor is 15 gtt/mL. How many drops per minute (gtts/min)will be administered? Round to nearest whole number.
51 gtts/min 1/60 x 1500/12 x 15/1 = 31.25, round to 31
A nurse is preparing for a midline dressing change with a patient who is extremely diaphoretic. Which of the following dressings is most appropriate for this patient?
A gauze dressing placed over catheter exit site A gauze dressing should be used with a patient who perspires excessively because it wicks the moisture away from the catheter exit site.
What is the nurse's initial action when preparing to change a patient's colostomy pouching system?
Applying clean gloves Applying gloves first will protect the nurse while checking the stoma for leakage and assessing the patient's skin for irritation. Although it is appropriate to drape the patient, FIRST put on gloves. The nurse will need to empty the pouch but this is not the best initial action. Although it is appropriate to assess the skin, doing so would not be the nurse's first action.
A nurse is teaching a new nurse about midline catheters. The nurse is asked about which intravenous infusions can be administered through a midline catheter. Which of the following responses would indicate the nurse needs more teaching?
Central parental nutrition Rationale: Central parenteral nutrition needs to be given through a central line. Administering through a midline line will cause phlebitis due to the osmolality of the CPN.
What would the nurse do before providing the patient with a scheduled intermittent feeding through a nasogastric (NG) tube?
Check NG tube placement. The nurse must check NG tube placement before providing a scheduled tube feeding. Listening to bowel or lung sounds would not give the nurse any information about NG tube position
You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding?
Check the drainage system for an air leak. Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak.
An 8-year-old child is about to receive an aerosol treatment via nebulizer. The nurse turns on the gas source to start the treatment and notes that no mist is coming out of the nebulizer. What is the first appropriate nursing intervention to perform?
Check the flowmeter setting and increase the flow until a most comes out of the nebulizer. The nurse should check the manufacturer's label to determine the correct liters per minute flow required. A mist should appear if the flow from the gas source is sufficient.
Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter?
Checking the documentation for the volume of fluid used to inflate the balloon Checking the amount of fluid used to inflate the balloon will tell the nurse how much needs to come out BEFORE removing the catheter to prevent injury to the urinary tract.
After changing the intravenous tubing on a patient's primary infusion, the nurse notes air bubbles in the tubing. How should the nurse remove them?
Close the clamp, stretch the tubing downward, and flick the tubing Closing the clamp is a preventative action to keep the air bubbles from going into the patient's IV. Flicking the tubing will create small vibrations to remove the bubbles from the tubing.
List 4 comfort care measures when patients are receiving supplemental oxygen delivery.
Comfort care: Nasal and oral dryness are common with noninvasive ventilation (NIV). Frequently assess the nares, lips, and oral cavity; as needed, apply a water-soluble lubricant to nostrils and lips and swab the mouth To avoid skin breakdown, which can occur when tubing rubs against the top of the ears or a a mask rubs the nose or cheeks, apply a foam dressing before attaching the device. Keep the head of the bed at an elevation of at least 30 degrees to improve ventilation Encourage the patient to take slow deep breaths to achieve maximum inhalation, which will promote optimal benefit from NIV
Which action can the nurse take to ensure a quality blood sample when drawing blood from a patient's peripherally inserted central catheter (PICC) site?
Discard the first 6-9 mL of blood drawn. Discarding the first sample reduces the risk of drug concentrations or a diluted specimen. Allowing fluid infusions to continue to flow right up to the time of the sample could alter the sample. Flushing the catheter after aspirating for blood return would have no effect on the quality of the sample. The patient need not be asked to rest before the sample is taken.
A patient receiving a unit of blood begins to show signs of a transfusion reaction. How frequently should the nurse monitor the patient's vital signs after stopping the transfusion?
Every 15 minutes 15 minutes is the standard time to monitor vital signs once a patient had a transfusion reaction. This allows the nurse to follow trends and see if the patient status is improving or worsening.
The nurse's best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago is to notify the surgeon of the bleeding.
False Bloody drainage 7 hours after surgery is still normal so the provider does not need to be contacted. If drainage increases and dressings become heavily saturated then the surgeon should be notified as internal bleeding could be present.
Chest tubes are used to drain fluid, blood, or air from the pleural space within the lung in order to re-expand a collapsed lung and restore the normal positive pressure in the pleural space.
False Chest tubes are used to drain fluid, blood, or air from the pleural space BUT they are used to restore the normal NEGATIVE pressure. When the patient has positive pressure it means that the intrapleural pressure becomes greater than the atmosphere causing a pneumothorax from increased pressure/air.
Nasal cannulas are the least common type of low-flow oxygen delivery system.
False Nasal cannulas are the most common type of low-flow oxygen delivery system.
To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at 2 L/ min - 5 L/min.
False To prevent exhaled carbon dioxide accumulation within a face mask, the flow rate must be set at more than 6 L/min.
What is a non-rebreather (NRB) mask? Explain in detail.
NRB masks have an attached reservoir bag (600 to 1,000 mL capacity) that allows for a higher concentration of oxygen delivery. Before placing the mask on the patient, the reservoir bag must be inflated to more than two-thirds full. As estimated one-third of the air from the reservoir bag is depleted as the patient inhales an dis then replaced by the flow from the oxygen supply. The one-way valve allows exhaled air to escape and prevents room air inhalation.
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will infuse properly?
Hang the piggyback medication higher than the primary fluid When a medication or any fluid is infused by gravity a pump is not necessary to run the infusion. Placing the secondary bag higher than the primary fluid will allow for the fluid to infuse at a faster rate than the primary bag with the help of gravity.
A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system?
Intermittent bubbling may be noted in the water seal chamber. It is normal to find intermittent (not continuous) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an air leak between the lung and chest wall, so the air will escape into the water seal chamber causing intermittent bubbles.
Which of the following are primary risk factors for pressure ulcers? Select all that appy.
Lengthy surgical procedures Low-protein diet Fever Protein is needed for adequate skin health and healing. During surgery the patient is on a hard surface for a long period of time and their body is not well protected from pressure on bony prominences. Fever causes diaphoresis so the patient's skin is moist leading to skin breakdown, and the stress on the body can cause their circulation to be impaired leading to a decrease in skin integrity.
What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?
Make a note on the lab slip that the patient is menstruating. The nurse would make a note on the lab slip that the patient is menstruating, to alert the lab to the possible source of any blood detected in the specimen. Menstrual blood in the specimen container may affect the test results, so it is necessary to notify the lab that the patient is menstruating.
Doctor orders 300 mg of Zmax once a day for a child that weighs 72 lbs. The safe dose range for this medication is 10-12 mg/kg/day. Is this a safe dose for this patient?
No, this is not a safe dose. A safe dose is 327.3-392.7 mg/day. The ordered medication is too low for the child, therefore it is NOT a safe dose for the patient. FALSE 72 / 2.2 =32.7; 32.7 x 10 = 327.3 72 / 2.2 = 32.7; 32.7 x 12 = 392.7 ^ Min and Max of the safe ranges
Which rhythm is shown? What is the rate?
Normal sinus rhythm rate 90 bpm
What would the nurse do if material aspirated from a patient's nasogastric tube resembled coffee grounds in color and texture?
Notify the health care provider. Coffee-grounds aspirate indicates bleeding. The health care provider should be notified.
When changing a midline dressing, the nurse notices redness, swelling, and drainage at the catheter exit site. Which of the following actions should the nurse take next?
Notify the practitioner Redness, swelling, and drainage at the catheter exit site are signs of infection, and the practitioner should be notified to make a decision regarding blood and catheter exit site cultures for further evaluation.
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain?
Pre-medicate the patient with a prescribed analgesic 30 minutes before the intervention. By pre-medicating the patient before the intervention it allows for the patient's pain to be controlled and for a comfortable state during dressing change. Distracting, re-positioning and explaining the procedure to the patient does not prevent or diminish the patient's pain.
When pouching a patient's colostomy, which action reduces the patient's risk for injury?
Protecting the skin from irritation caused by fecal drainage Protecting the skin from irritation caused by fecal drainage ensures correct pouching and prevents injury associated with skin breakdown.
The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately?
Redness noted on the external urethral meatus Redness surrounding the external urethral meatus is a sign of impaired skin integrity and should be reported to the nurse immediately.
How can the nurse minimize the risk of dislodging the catheter when removing a dressing?
Remove the transparent dressing or tape and gauze in the direction of catheter insertion. The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change. Skin protectant should be applied before placing a new catheter stabilization device.
A patient receiving a unit of blood complains of feeling cold and begins to have shaking chills. What is the nurse's first action?
Stop the infusion The patient feeling cold and shaking is a reaction to the infusion. The infusion needs to be stopped to prevent further reaction from the blood being given.
List three verifications, that must be included when delivering supplemental oxygen to a patient.
The three verifications of delivering supplemental oxygen must include: The right physiologic criteria The right equipment The right environment
A patient experiencing a blood transfusion reaction is prescribed to receive epinephrine. What is the purpose of this medication when given for this indication?
To relieve respiratory distress When a patient has an infusion reaction they can experience bronchoconstriction, as they would with another allergic reaction. The administration of epinephrine will allow for the bronchioles to dilate allowing for proper gas exchange to occur in the lungs, thus relieving respiratory distress.
Noninvasive ventilation delivers ventilatory support without an artificial airway (endotracheal or tracheostomy tube) to patients who can breathe spontaneously.
True
Oxygen delivery devices are categorized as low-, moderate-, and high-flow.
True
Simple face masks are used in patients who require short-term, higher oxygen concentration, such as FiO2 35% to 60%.
True
The nurse will monitor the patient and equipment when their patient is receiving supplemental oxygen. Encouraging and helping the patient change positions frequently and to cough and deep breathe to improve ventilation and circulation are highly encouraged as patients are monitored.
True
The best action and most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field is to position the height of the table to be above waist level.
True The area in front and above the waist is considered sterile. Having supplies and the field set up below that has the risk of contaminating the sterile field.
When drawing blood from a patient's peripherally inserted central catheter (PICC), what should the nurse do to minimize the pressure on the device during flushing?
Use a 10-mL syringe for the flush A 10-mL syringe would be used during the flush to minimize pressure on the device. Clamping the device would hinder the nurse's ability to flush the catheter. A 3-mL syringe would not reduce pressure on the device during the flush.
Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient's comfort when a condom catheter is applied?
Use a hair guard before applying the condom catheter. To ensure the patient's comfort, the nurse would instruct NAP to use a hair guard before applying the condom catheter, and will prevent hair pulling leading to skin irritation.
Which activity is important to include in the plan of care of a patient with a peripherally inserted central catheter (PICC)?
Use a sterile technique when changing the PICC dressing. Using sterile technique is the most important to include because it decreases risk of bacteria entering the body, going directly to heart, and causing infection (endocarditis or myocarditis). Changing IV tubing is important but not a priority over maintaining a sterility during dressing change. You would NOT place a blood pressure cuff on the arm with the PICC line.
NIV benefits include all of the following: (you may choose more than one correct answer)
preserving natural airway defenses allows the patient to eat and drink keeping the upper airway intact allows the patient to communicate verbally NIV benefits include keeping the upper airway intact, preserving natural airway defenses, self-expectorating secretions, and allowing the patient to eat, drink, and communicate verbally.
Match the following related to oxygenation. Ventilation Respiration Low-flow devices Moderate-flow devices High-flow devices
Ventilation - The movement of air in and out of the lungs is controlled by the neurologic and musculoskeletal systems. Respiration - Oxygen and carbon dioxide exchange in the lungs. Is controlled by the pulmonary and cardiovascular systems Low-flow devices - Nasal cannulas, face masks, and NRB masks Moderate-flow devices - Partial non-rebreather (PRB) masks High-flow devices - Venturi mass, HFNCs
Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
Wear clean gloves to remove soiled dressings Wearing clean gloves to remove soiled dressings minimizes the risk of cross-contaminating the wound. The proper procedure is to wipe away old exudate by swabbing outward from the wound.
Which of the following statements would be considered incorrect when transfusing packed red blood cells (RBCs)? (select all that apply)
Wrong Statements: Begin an infusion of D5W prior to the packed RBCs Adjust the infusion rate to ensure unit is unfused within 6 hours Correct Statements: Obtain baseline vital signs, including temperature and pulse oximetry Verify the patient ID and blood unit number with another nurse prior to administration. When infusing RBCs the infusion should not exceed 4 hours. Administering D5W before RBCs is not necessary and causes an increase in serum glucose. Obtaining vital signs and proper identification are safety precautions taken for the patient.
Which rhythm is shown?
atrial fibrillation
Which rhythm is shown?
atrial flutter