BN Ch 22 Care of pt with alterations in health
What are the Pre-procedure steps?
1) Check chart for MD orders 2) Introduce yourself 3) Identify the patient 4) Explain procedure 5) Wash hands
Identify five purposes of IV therapy (p 627)
1) Maintain fluid volume 2) Replacement for fluid lost 3) Give medications 4) Give blood or blood products 5) Nutritional support *The IV route provides faster absorption and more rapid distribution of medications, solutions, or nutrients and can be used for either long-term or short-term applications.
Identify five possible complications of IV therapy (p 631 & 633)
1) Pulmonary Congestion 2) Shock 3) Thrombophlebitis 4) Infiltration 5) Phlebitis 6) Inflammation
What are the five rights of delegation? (p 614)
1) Right Task 2) Right Circumstance 3) Right Person 4) Right Direction 5) Right Supervision/Evaluation
There is less than 100mL left in the IV bag and the nurse's shift will end in 30 minutes. The infusion pump is set to deliver 125mL/hr. What should the nurse do? (p 632) A) Alert the oncoming nurse about the amount left in the bag B) Slow the infusion down so the fluid will last at least an ht C) Hang a new bag and record IV fluid intake 900mL D) Convert the IV to a saline lock to prevent air embolism
A) Alert the oncoming nurse about the amount left in the bag *When solution has less than 100mL remaining, have a new bag of solution at pt's bedside so that it is readily available for changing. This reduces the risk of air entering the tubing and the pt's vein.
There are principles to consider when using heat and cold therapy for pts. The nurse recognizes that the: (p 627) A) Application usually lasts only 10-20 minutes B) Pt should adjust the temperature settings for comfort C) Pt should move application around for relief D) Application is positioned for convenient observation
A) Application usually lasts only 10-20 minutes
Upon assessment of the IV insertion site, the nurse suspects that the pt has phlebitis. This is based upon the observation of : (p 636) A) Edema st the site B) Erythema along the vein C) Cool skin around the site D) Sluggish flow of IV fluid
A) Edema at the site *Erythema, warmth, edema, and discomfort are classic signs of phlebitis.
A blood transfusion is prepared for a pt. In setting up the IV, which solution does the nurse use to flush the tubing? (p 644) A) Normal Saline B) 5% dextrose in water C) 10% dextrose in water D) Ringers solution
A) Normal saline *When a blood transfusion is begun, a primary IV infusion of 0.09% or 0.45% normal saline is started with a Y administration set. Dextrose should not be uses because it causes the blood the lyse or be destroyed.
The nurse us going to change the dressing of the peripheral IV line. Which action(s) is/are part of the correct technique for this procedure? (Select all that apply) (p 638) A) Palpate the catheter site after the old dressing is removed B) Leave the catheter stabilization device (or tape) in place C) Discontinue the infusion site with tape D) Cover the insertion site with tape E) Place tape over the transparent dressing F) Label the dressing with the date, time, and initials
A) Palpate the catheter site after the old dressing is removed B) Leave the catheter stabilization device (or tape) in place F) Label the dressing with the date, time, and initials
The nurse is preparing the IV setup so that IV solution will be immediately ready when IV catheter is inserted. Place the steps of IV tubing in the correct order: (p 632) A) Select tubing based on pt condition and type of insulin B) Make sure the roller or side clamp is functional C) Close the clamp D) Uncoil tubing and inspect it for kinks E) Remove the tubing from the sterile packaging
A) Select tubing based on pt condition and type of insulin E) Remove the tubing from the sterile packaging D) Uncoil tubing and inspect it for kinks B) Make sure the roller or side clamp is functional C) Close the clamp
In performing nursing skills and procedures for pts, which nursing action demonstrates the nurses understanding and use of standard precautions? (p 614) A) always checks the pt's armband and asks the pt to state his/her name B) assesses the pt's understanding and teaches accordingly C) performs hand hygiene before and after every pt encounter D) evaluate the pts response to and tolerance of ther procedure
A) always checks the pt's armband and asks the pt to state his/her name B) assesses the pt's understanding and teaches accordingly C) performs hand hygiene before and after every pt encounter D) evaluate the pts response to and tolerance of ther procedure (All actions demonstrate the nurses knowledge and understanding of the standard precautions)
The home health nurse is observing a family member assist the pt with a heating pad. The nurse should intervene if the family member performs which action? (p 624) A) assist the pt to lie on the heating pad B) adjusts the pad to the lowest temperature setting C) place a cloth between the skin and the heating device D) checks the electrical cord for fraying or kinks
A) assist the pt to lie on the heating pad *Instruct pt not to lie on heating pads; the heat can not disperse appropriately and may cause burns
A patient complains of burning sensation and swelling at the intravenous (IV) infusion site. What intervention would be most suitable in this situation?
Stopping the infusion and continuing the IV therapy from another site
T/F: PICC lines pose a risk of pneumothorax, hemothorax, and air embolism than CVCs, are less expensive to maintain than CVCs, and pose less risk of phlebitis and infiltration than peripheral lines (p 635)
True
A primary health care provider prescribes nasal irrigation for a patient suffering from inflamed nasal mucous membranes. What instruction should the nurse give the patient during this procedure?
"Breathe through your mouth during the procedure."
A patient is being discharged home. Instructions regarding cold therapy have been explained. Which statement if made by the patient indicates a knowledge deficit regarding care after discharge?
"I will place the ice pack directly on the wound."
A patient with a colostomy is being discharged home. The ostomy nurse and the patient have had several teaching sessions regarding stoma care after discharge. Which statement if made during the session indicates the patient lacks a thorough understanding of ostomy self-care?
"When applied correctly, I should feel pressure from the ostomy appliance."
A patient has a urinary catheter removed after several weeks. Which interventions if carried out by the nurse would stimulate the patient to void? Select all that apply.
-Running water in the sink -Encouraging the male patient to stand -Placing the patient's hands in warm water
The maximum amount of fluid that should be administered to an adult during a tap-water enema is ___? (p 687)
1000mL
A patient is being discharged home, and the peripheral intravenous (IV) site is to be discontinued. After the removal of the catheter, what is the minimum length of time the nurse should hold pressure?
2 to 3 minutes
When inserting a urinary catheter into a female pt, the nurse knows that it should be inserted _____ inches. (p 667)
2-4 inches
Even when and ostomy pouch is adhering well, it is best to change it at least every ___ days to allow for observation of the stoma and the skin around the stoma? (p 694)
3-5
For infants, the pressure of the wall suction should be set at ____ during suctioning airways? (p 659)
60-80 mm Hg
Can be given with blood loss during surgery or after traumatic injury. Pt may donate their own blood before anticipated surgery
Autologous blood Transfusion
A primary health care provider gives instructions to the nurse to perform an internal vaginal irrigation for a patient prior to vaginal surgery. What precaution does the nurse take while douching the patient?
Avoid washing away the secretions of the vaginal membrane.
A patient with a urinary drainage system is at risk for infection. What intervention will help reduce this risk?
Avoiding placing the drainage bag above the level of catheter insertion
The nurse applies heat to a fairly large area on the pt's trunk. The pt reports feeling slightly dizzy and his pulse is rapis. What is the best physiologic explanation for the systemic reaction? (p 620) A) The heat application has triggered a fever B) The trunk contains some large blood vessels C) The application is causing vasodilation D) Antibodies and leukocytes are activated
C) The application is causing vasodilation *Vasodilation causes increased blood flow to the area of the body being treated; as a consequence, blood flow to the rest of the body decreases, which can potentially result in increased pulse, dizziness, and shortness of breath.
Which pt is the most likely candidate for the use of a Morgan Lens to flush the eye? (p 617) A) pt has an allergic conjunctivitis in both eyes B) pt was sprayed in the eyes with pepper spray C) pt needs frequent eye irrigation at home D) pt had pain after prolonged use of contact lens
C) pt needs frequent eye irrigation at home
A cold application is ordered for the pt. The nurse is aware that a positive effect of this treatment is: (p 620) A) Vasodilation B) Local anesthesia C) Reduced blood viscosity D) Increased Metabolism
B) Local anesthesia
Just before IV line insertion, the nurse should: (p 629) A) Shave the hair from the selected site B) Select a proximal site on the upper extremity C) Apply a tourniquet to impede venous flow D) Vigorously massage the extremity to be used
B) Select a proximal site on the upper extremity
Upon assessment of pts IV site, the nurse determines that the site has been infiltrated. What are the signs and symptoms that the most has most likely just observed? (p 635) (Select all that apply) A) Warmth at the insertion site B) Swelling at and above the insertion site C) Redness at the insertion site D) Coolness at and above the insertion site E) Sluggish flow of the IV fluid
B) Swelling at and above the insertion site D) Coolness at and above the insertion site E) Sluggish flow of the IV fluid
The nurse must perform catheter care. Prior to starting the procedure, the nurse raises the bed and lowers one side rail. What is the best rational for this action? (p 614) A) ensures pt safety and comfort B) promotes good body mechanics C) facilitates visualization of body D) adheres to standard procedure
B) promotes good body mechanics ( B and D are both correct but B is the most correct)
Why should ear irrigation always be done with room temperature solutions?
Because cold solutions cause vertigo.
Achievement of voluntary control over voiding; it often involves developing the use of muscles in the perineum
Bladder Training
Involves introducing a rubber or plastic tube through the urinary meatus and the urethra into the urinary bladder
Catheterization
During colostomy irrigation, the nurse finds that the patient has a pressure sore in the area around the colostomy. What intervention would help this patient?
Change the size of the ostomy appliance in the patient.
The nurse is at home and her husband accidentally gets a caustic chemical splash in his eyes. What should the nurse do first? (p 615) A) Drive him to the hospital and flush his eyes with normal saline B) Call poison control and ask for advice about the specific chemical C) Gently flush his eyes with tap water for at least 15 minutes D) Assess him for burning, changes in visual acuity, or pain
C) Gently flush his eyes with tap water for at least 15 minutes *When caustic chemicals enter the eye, make sure to gently flush the eye continuously for at least 15 minutes with tap water to prevent burning of the cornea, and refer the pt immediately to a health care provider.
The pt was diagnosed with a sprained ankle and the health care provider recommended a cold application for 20 minutes. Which condition would cause the nurse to question the order? (p 621) A) The Pt's ankle is already slightly swollen B) The pain medication has not had time to work C) Pt has a history of peripheral vascular disease D) The pt tells the nurse that 20 minutes is too long
C) Pt has a history of peripheral vascular disease *Body's extremities are less sensitive to temperature and pain stimuli because of circulatory impairment and local tissue injury. Cold application further compromises blood flow.
The nurse is giving instructions to the UAP about applying a warm, moist compress to a small abscess in the pt's axilla. What instructions should the nurse give? (select all that apply) (p 624) A) Compress should be 105-110 degrees F B) Apply for 10-20 minutes C) Report pain, exudate, or redness D) Notify about completion of therapy E) Evaluate the response to therapy
C) Report pain, exudate, or redness D) Notify about completion of therapy
Collection of feces in the rectum in the form of a mass that becomes so large or hard that the pt is unable to pass it voluntarily
Fecal Impaction
Which intervention, if carried out by the nurse, is most effective to prevent skin breakdown in an incontinent patient? -Provide bladder training -Inserting a Foley catheter -Using the Crede maneuver -Changing undergarments and pads frequently
Changing undergarments and pads frequently
Crossing the tape over the catheter
Chevron
Surgical creation of a stoma on the abdominal wall where the colon is normally attached
Colostomy
Warmed, moist cloths used to reduce inflammation
Compresses
The health care provider has ordered the application of a warm compress to a pt's leg wound. What does the nurse tell the pt about the compress? (p 624) A) "We soak your leg in warm solution that has antibiotic medication for at least 30 minutes a day." B) "We wrap your leg with a towel and then apply a dry heating device that is similar to a heating pad." C) "We apply a hot water bottle to your leg and then wrap a towel around it to retain the warmth." D) "We apply a sterile, moist gauze dressing to the wound, then wrap it with a warm waterproof heating pad."
D) "We apply a sterile, moist gauze dressing to the wound, then wrap it with a warm waterproof heating pad."
The pt has had prolonged nausea and vomiting which requires IV hydration. On assessment the skin turgor is poor and veins are flat and not easily palpated. Which IV catheter is the nurse most likely to use? (p 632) A) 16 gauge B) 18 gauge C) 20 gauge D) 22 gauge
D) 22 gauge *Many pts who require IV hydration have such low blood volume that only the smaller gauge IV catheters suffice for venipuncture.
Which pt is an appropriate candidate for an ear irrigation? (p 617) A) a child who inserted a pinto bean into the ear canal B) a toddler who has a severe ear infection with exudate C) a teenager who has bleeding from the ear after a fight D) an elderly pt who reports a crackling noise in the ear
D) an elderly pt who reports a crackling noise in the ear *Ear irrigation is contraindicated if the pt has a cold, an elevated temp, an ear infection, or an injured or ruptured tympanic membrane. Ear irrigation can cause a vegetable foreign body to swell up
The nursing student has the opportunity to perform urinary catheterization for a pt. What should the student do first? (p 614) A) perform hand hygiene and don gloves B) explain the procedure to the pt C) obtain the necessary equipment D) check the health care provider's orders
D. Check the health care provider's orders This is the very first step in the standard steps. You always check the order before any procedure is done.
If no wax is present in the ear
DO NOT irrigate
Elimination of bowel wastes; a basic human need & is essential for normal body function
Defication
Caused by too rapid an infusion of highly concentrated feedings
Dumping syndrome
The nurse is caring for a pregnant patient with hemorrhoids. What suggestion does the nurse give to the patient regarding diet?
Eat a diet rich in fiber
The instillation of a solution into the colon via the anus
Enema
T/F: Suctioning to keep the airway patent eliminates the need for the pt to perform coughing and deep-breathing (p 657)
False: A pt who is able to expectorate secretions require less suctioning
T/F: Oxygen will explode if someone lights a match while standing close to a pt who is using oxygen. (p 646)
False: Oxygen does not burn but it does support combustion
T/F: The nurse should delegate to the UAP to routinely assist the home health pt with vaginal douching for hygiene (p 694)
False: Routine internal vaginal irrigation, or douching, tends to wash away protective agents
T/F: Pts with colostomies are at a high risk for skin impairment at the site due to nearly continuous urine drainage. (p 694)
False: pts with UROSTOMIES are at a higher risk for skin impairment at the site due to nearly continuous drainage of urine
Presence of air or gas in the intestinal tract, typically occurs when consumes gas producing liquids and foods such as carbonated beverages, cabbage, or beans; swallows excessive amounts of air; or is constipated
Flatulence
Pain is an issue with both....
Heat and cold
Place the steps in the correct order for connecting the IV tubing to the ordered IV solution bag: (p 632) A) Remove the solution from the package and check expiration date, for any leaks, or any contamination B) hold the fluid bag upright and squeeze drip chamber to fill one-third to one-half C) Slowly open the clamp and prime tubing D) Invert bag to allow easy access to the tubing insertion port E) Remove the insertion port cover from the tubing spike F) Close the clamp when the tube is fully primed G) Insert the spike into the port until the plastic diaphragm covering the port is pierced H) As fluid fills the tubing, invert injection ports to fill them I) Remove the tubing from the sterile packaging, inspect it for kinks and close the roller or slide clamp
I) Remove the tubing from the sterile packaging, inspect it for kinks and close the roller or slide clamp A) Remove the solution from the package and check expiration date, for any leaks, or any contamination D) Invert bag to allow easy access to the tubing insertion port E) Remove the insertion port cover from the tubing spike G) Insert the spike into the port until the plastic diaphragm covering the port is pierced B) hold the fluid bag upright and squeeze drip chamber to fill one-third to one-half C) Slowly open the clamp and prime tubing H) As fluid fills the tubing, invert injection ports to fill them F) Close the clamp when the tube is fully primed
Opening in the ileum (the distal part of the small intestine)
Ileostomy
The inability to control urine or bowel elimination
Incontinence
Stop treatment of heat if any of the following are present:
Increased pulse, dizziness, shortness of breath
Hardness
Induration
Seepage of nonirrigating solution or medication into tissue surrounding the vessel
Infiltration
A patient had heavy blood loss during surgery. Which is the most preferable method, in addition to blood transfusion, to increase the blood volume in the patient?
Infusing lactated Ringer's solution
Infusion of medication or other liquid therapeutic agents
Intravenous (IV)
Involves a gentle washing of an area with a stream of solution delivered through a syringe
Irrigations
A nurse is preparing a patient who is to receive a cleansing enema. The patient is assisted to which position?
Sims
Device consisting of small tubes inserted into the nares. Simple, two-pronged plastic device that is used to deliver low concentrations of oxygen
Nasal Cannula
Flexible, hollow tube that is passed into the stomach via the nasopharynx
Nasogastric (NG) tube
The licensed practical nurse (LPN) is assisting a primary health care provider in inserting an intravenous catheter into a patient with dehydration. Which intervention would help in preventing vein damage in the patient?
Never leave the tourniquet on for longer than 1 minute
Artificial opening, site of the opening is called a stoma
Ostomy
What is true regarding a patient who receives oxygen via the transtracheal method?
Oxygenation is usually achieved with less oxygen flow than with other systems
A patient reports painful joints due to arthritis. Which is the best intervention for relieving pain in the patient?
Paraffin bath
Openness
Patency
Distal from the heart
Peripheral
Eythema, warmth, edema, & discomfort are classic signs of what?
Phlebitis
Inflammation of the vein
Phlebitis
A primary health care provider asks the nurse to insert a urinary catheter for a patient. Which nursing action needs to be corrected during the insertion of the urinary catheter?
Placing the drainage bag above the catheter level
A patient is receiving an intravenous (IV) infusion of blood. Once the infusion has begun, for what length of time should the LPN expect the RN to stay with the patient to monitor vital signs and watch for an allergic reaction?
The first 15 to 20 minutes
A patient with a primary intravenous (IV) infusion of normal saline is due to have an antibiotic at noon. The antibiotic is removed from the medication-dispensing machine and mixed in a secondary bag. What sign indicates the medications are incompatible?
The infusion has sediment in it.
The nurse is cleansing the perineal area of a male patient. Which order of effective cleansing does the nurse follow?
The nurse cleanses the top of the penis and then moves down in a circular motion
The nurse is caring for a patient who is on intravenous (IV) infusion. The patient reports pain and swelling at the IV site. What complication is most likely to occur in the patient?
Thrombophlebitis
While administering oxygen to a patient with respiratory distress, the nurse places a nasal prong into each of the patient's nostrils. Why does the nurse use a nasal prong?
To direct the flow of oxygen into the upper respiratory tract
Artificial opening made by a surgical incision into the trachea
Tracheostomy
T/F: Intermittent urinary catheterization has a low risk of infection than an indwelling catheter due to the relatively shorter time the catheter remains in the bladder (p 693)
True
T/F: Once nasogastric tube placement has been verified by x-ray, the nurse can safely use it for routine feedings. (p 694)
True
rubber or plastic tube inserted through the urinary meatus and the urethra into the urinary bladder
Urinary catheter
Diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin
Urostomy
A nurse inserts a peripheral intravenous (IV) line. Which intervention, if implemented by the nurse, can place the patient at risk for an infection?
Using the chevron method of securing the IV catheter in place
Narrowing of blood vessels
Vasoconstriction
Dilation of the blood vessels
Vasodilation
Access of a vein with a needle for the purpose of starting an IV or withdrawing a blood sample
Venipuncture
When should ear irrigation NOT be done?
When a vegetable foreign body is obstructing the canal, when the patient has a temperature, cold, ear infection, or ruptured tympanic membrane
How should eye irrigation be performed?
from inner to outer canthus
The two most common complications of central venous catheters are ____ and ____ of the catheter cannula? (p 634)
infection and occlusion
A patient is receiving temporary feedings via a nasogastric tube. In which position should the nurse place the patient to prevent gastric reflux?
it is essential for the nurse to keep the head of the bed elevated 30 degrees because this prevents aspiration or reflux. (Fowlers)
What are eye irrigation used for?
used to flush out debris or caustic solutions, relieve conjunctiva irritation, or apply antiseptic solutions
How is warm saline instilled?
using a small syringe or eyedropper
