Skills exam 5

Positive TB look like

15mm or more- no risk factors 10mm or more- immigrants, drug users, residents/ employees high risk facilities, chronically ill, children under 4yo 5mm or more- HIV +, fibrotic changes in X-ray, hx TB, immunosppressed

Sites for ID injections

Inner aspects of forearm Scapular area of back May use- outer aspects of arm or upper chest

indwelling catheter

remains inside the body for a prolonged time based on need

Amount of pressure for adult suction

100-150 mmHg

Ventrogluteal site

20-25g for aqueous 18-25g for viscous 1/2- 2inches length 1/2- 1 inch for children 1-3mL volume (max 5mL)

Needle length and gauge for sub-q MMR injection

21-25 g 1/2 inch

Needle size for subQ

23-25g

Needle size for ID

26-27g

Angle for SubQ

45-90

Angle for ID

5-15 degrees

How long after removal of catheter should pt void

6 to 8 hours

Amount of pressure for neonate suction

60- 100

Angle for IM injection

90 degrees

Which statement is correct regarding negative pressure wound therapy

A suction pump is used Chronic ulcers are reduced by removing fluids from the wound

Tips for subq

When using insulin or heparin continue to pinch skin while injecting Do not massage the site

What complication does air not in the tubing prevent

Air embolism

sites for subQ

Back of arms Thighs Stomach

Proper way to administer ampule

Breakaway from you Always use hand protection Use **filter needle** to draw up medications Always change needles prior to injection

Deltoid site

Children above 18 mo 20-25g for aqueous 18-25g for viscous Length 1/2 -1 inch Up to 2mL volume

Which action would the home health nurse take when caring for a client with pink& moist left leg venous stasis ulcer

Clean the wound with normal saline & apply prescribed hydrocolloid dressings weekly

A client has a large open abdominal wound. The HCP prescription states to clean with normal saline, pack it with damp gauze, cover with abdominal pads & secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing

Cleanse the wound with wet sterile guaze from the center of the wound outward

While caring for a client with a portable wound drainage system, the RN notices the collection container is half full. The RN empties the container. Which intervention should the RN do next?

Compress the container before closing the port

D5W

Dextrose 5% in water

Proper technique for z track method

Displace skin and subcutaneous layer tissue laterally for z teach method

What can be delegated to the UNP for a client with pressure ulcers

Empty wound drainage Report changes in wound appearance

What way should wounds be cleansed?

From the center outward or top to bottom

Hypertonic

Greatly expanded intravascular spaces Irritating too vein Increase risk of HF D5NS, D5LR, D10W

Which dressings would the nurse view as beneficial for the recovery of a clients red colored wound that was caused by pressure?

Hydrocolloid dressings Transparent film dressings Non adhering dressings from antibiotic ointment

a RN is evaluating the statements of a new nurse about wound dressings. Which statement is incorrect

I should use the cotton swab placed on the table

IVPB

Iv piggy back

Which interventions promote perfusion and healing of the surgical wound of an older adult

Keep the patient adequately hydrated

LR

Lactated ringers

What insulin's can not be mixed with other insulins

Lantus Levemir

Hypotonic

May cause sudden fluid shift from vessels into cells Can exacerbate hypotension 1/3 NS, 1/2 NS

What is normal in urostomies but not colostomies

Mucus

NS

Normal saline

The RN is about to perform wound irrigation on a client who had a left hemispheric stroke. What assessment is the most important prior to wound irrigation?

Pain

Which action would the RN take 1st after observing serosanguineous drainage on the abdominal dressing of a client in PACU who had an abdominal cholecystectomy?

Reinforce the dressing

The RN assesses the clients incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the RN's conclusion the client is experiencing a wound dehiscence?

Sharp increase of serosanguineous drainage

Where and what do newborns get injected

Vitamin K Vastus lateralis

A RN teaches a family member to cleanse a clients wound and apply sterile dressing. Which action by the family member indicates the need for further education?

Using back & forth motion with the same gauze while cleaning

How would the RN classify a wound that exhibits some soft necrotic tissue with a semiliquid slough & exudate

Yellow

straight catheter

a catheter that drains the bladder and then is removed

Coude catheter

curved and has a rounded or bulbous tip that is easier to insert into the male urethra when the prostate is enlarged.

Sites for IM injections

deltoid, ventrogluteal, vastus lateralis

D5LR

dextrose 5% in lactated Ringer's

D5NS

dextrose 5% in normal saline

PCA

patient controlled analgesia

TKO

to keep open (vein)