Advanced Skills For Healthcare Providers Final Review Chapter 1-17

The percentage of enteral formula is:

15 percent solid

The normal blood sugar range is:

65-120

An example of dry heat treatment is:

A hot water bottle

When changing a used needle, always use:

An instrument

Incontinence is a normal aging change: T/F

False

Patients who have had hip surgery are at very high risk of developing:

Heel ulcers

Abnormally high body temperature is:

Hyperpyrexia

The AV junction is:

In the general area of the AV node

Renal calculi:

Kidney stones

When caring for a patient with a nephrostomy tube, repoet to the RN if:

There is copious yellow drainage at the insertion site

direct laryngoscopy:

Visualization of the larynx, vocal cords, and structures in the back of the throat with a laryngoscope

You enter a room and find the patient with no pulse or respirations. Your first actions is to:

call for help

Compartment syndrome:

• Serious complication that may develop following an injury or surgical procedure • Occurs when pressure within the muscle builds up preventing blood and O2 from reaching muscles and nerves Compartment syndrome is a surgical emergency

You are working with a patient who has paralysis of the left arm. The RN instructs you to ask the patient to wash her face independently. The best way to direct the patient is to say:

"You can use your right arm."

The pH of fluid aspirated from the stomach is usually:

0 to 5

The pH of stomach contents may range from:

0 to 5

Each small block on the ECG/EKG paper represents:

0.04 seconds

Each large block on the ECG/EKG paper represents:

0.20 seconds

Most tube-feeding formulas deliver approximately:

1 calorie per mL

pH of Body Fluids: 1) Stomach 2) Intestinal contents 3) Respiratory secretions

1) 0 to 5, most commonly 1 to 4 2) 6 to 8, most commonly 7.5 to 8 3) Usually 7 or higher, can be as low as 6

2 way of opening the airway are:

1) head tilt chin lift maneuver 2) jaw thrust maneuver

S/S of inadequate breathing to report to the nurse involve:

1) movement in the chest is absent, minimal, or irregular. 2) breathing movement appears to be in the abdomen, not the lungs. 3) air movement can not be detected by listening and feeling for breath on your ear and cheek. 4) respiration rate is too slow or too rapid. 5) respirations appear labored. 6) respirations are irregular, gasping, very deep, or shallow. 7) patient is short of breath. 8) respirations are noisy. 9) nasal flaring is present during inspiration. 10) Accessory muscles retract inward during respirations.

Monitoring for breathing adequacy involves:

1) the patient talking, respirations are 12-20 and no apparent distress. 2) the rhythm is regular. 3) the patient's color is normal, no signs of cyanosis or gray coloration. 4) Patient's chest expands equally with each inspiration. 5) breath sounds are heard by placing your ear next to the patient's nose and mouth. 6) Patient's breathing is felt on your cheek and ear.

When changing an ostomy bag, cut the hole for the stoma:

1/8 inch larger than the stoma

A macrodrip administration set delivers:

10-20 drops per Ml

When performing one-person CPR on an adult, compress the sternum at a rate of:

100 per minute

The normal respiratory rate in an adult is between:

12 and 20 per minute

Normal respiratory rate for a teenager is between:

12 and 26 per minute

Pre-hypertension is blood pressure value between:

120/80 & 139/89

When connecting an oxygen source to the bag valve mask, set the liter flow at:

15 liters per minute

The water temperature in the hydrocollator should be between:

160 F to 166 F

A 2-hour postprandial blood sugar is collected:

2 hours after meals

Heat and cold applications are usually not left in place longer than:

20 minutes

When the pacemaker is in the ventricles, the heartbeat is usually:

20 to 40 beats per minute

Room air contains approximately how much percentage of oxygen:

21 percent

Normal respiratory rate for a preschool child is between:

22 and 34 per minute

Normal respiratory rate for a toddler is between:

24 and 40 per minute

In healthcare facilities the goal is to defibrillate within:

3 minutes

Glycated hemoglobin (A1C) is a measure of blood sugar control over a period of:

3 months

Normal respiratory rate for an infant is between:

30 and 60 per minute

When using a syringe for procedures related to a feeding tube, select a:

30 mL syringe

When the pacemaker is in the AV node, the heartbeat is usually:

40 to 60 beats per minute

Following an injury, heat should not be used for:

48 hours

When a patient begins using the hyperthermia-hypothermia blanket, check the vital signs every:

5 minutes until the patient's temperature reaches the designated value

When the pacemaker is in the SA node, the heartbeat is usually:

60 to 100 beats per minute

Normal range of blood sugar is:

65 and 120, with the normal value commonly being 70 - 110: Values below 70 suggest hypoglycemia Values above 110 suggest hyperglycemia

When testing urine specific gravity, the specimen should be approximately:

71ºF

The whirlpool bath should be set at:

97 F to 100 F

When collecting blood from an adult, select:

A 20-to 23- gauge needle

Deep vein theombosis is:

A blood clot in the deep veins of the legs

Gastric analysis:

A laboratory test done to check for the presence of acid in the stomach

Glycated hemoglobin/Ghb/glycohemoglobin/glycosylated hemoglobin/HbA1c/HbA1/%A1C:

A measurement of glucose levels in the blood over the past three months; abbreviated %A1C

Tension pneumothorax:

A serious condition in which air trapped between the lungs and chest wall cannot escape, leading to a steady buildup of pressure

When doing A1C testing, you should use:

A single-use,disposable meter

Endotracheal tube (ET tube):

A tube that is passed through the mouth, or less commonly the nose, into the patient's lungs for the purpose of ventilation.

After hip replacement surgery, keep the patients legs apart by using a:

Abduction pillow

pH is a measure of:

Acidity or alkalinity

The PCA pump enables the patient to:

Administer pain medication

You are administering a gastrostomy tube feeding by the bolus method. You should:

Allow the fluid to flow in by gravity, adding fluid before the syringe empties

After the arteriogram, avoid:

Ambulating the patient early

The gastrostomy tube button is most commonly used for:

Ambulatory patients

A Doppler instrument:

Amplify sounds within the body

Buried bumper syndrome is:

An ulceration of the tissue at the feeding tube exit site or the internal mucosal layer of the gastric wall that may occur with a tube that has internal and external retention bumpers holding the tube in place. • S/S that should be reported to the RN include: 1) Bleeding from the stoma 2) Formula leakage 3) Leakage of gastric secretions 4) Sudden onset of intolerance to formula that the patient tolerated previously

An angiogram or arteriogram is:

An x-ray study of the blood vessels

When applying a heat or cold application:

Apply the principles of standard precautions

The IV solution should hang:

At least 30 inches above the needle insertion site

When positioning a patient who is postoperative ORIF, you should:

Avoid adduction and internal and external rotation of the affected hip

S/S of transfusion reaction include:

Back pain

NG tube insertion and care:

Because the stomach and lungs share the same internal structures in the back of the throat, a tube may be inserted into the lungs. If this occurs withdraw the tube. Placement of the tube can be determined by x-ray.

Hypothermia is body temperature:

Below 95 F

Avoid drawing blood from the feet and legs because this increases the risk of:

Blood clots

The main purpose of pneumatic compression hosiery is to prevent:

Blood clots

Blood in the stool will turn the Hemoccult developing solution:

Blue

Before inserting a tube into the centrifuge, you should:

Check the tube for cracks and chips

The most accurate bedside method of checking for enteral tube placement is:

Checking the pH of fluid aspirated from the tube

S/S of tension pneumothorax:

Chest pain, hypotension (low B/P), distended neck veins, tracheal shift to one side, hypoxemia (low O2 levels in the blood), rapid or weak pulse, dyspnea (difficulty breathing), rapid respirations, diaphoresis (sweating)

The term cryotherapy refers to:

Cold therapy

To collect a throat culture:

Collect the swab specimen from the back of the throat, wipe the tonsil area from site to side with the applicator and swab all areas.

Two-hour postprandial blood sugars (PPBS):

Collected exactly 2 hours after the patient finishes eating.

SIGNS & SYMPTOMS OF HYPOGLYCEMIA

Complaints of hunger, weakness, dizziness, shakiness Skin cold, moist, clammy, pale Rapid, shallow respirations Nervous and excitement Rapid pulse Unconsciousness No sugar in urine Low blood sugar as measured by FSBS

An enteral tube:

Conducts nutrients and fluids into the GI tract

Signs and symptoms of hypoglycemia, List 4:

Confusion Sweats Dizzy Nausea Shaky hungry weak dizzy shaky skin is cold, moist , clammy nervous/ excitied rapid pulse unconsciousness

A dressing:

Contacts the wound directly

A wound that is colonized:

Contains microbes that have reproduced

S/S of tube going into the lungs may include:

Coughing Choking Or the patient may become cyanotic

Necrotic tissue is:

Dead, devitalized tissue

A factor that affects the condition of the veins is:

Dehydration

When a patient uses a urinary leg bag, you should:

Disinfect the leg bag and bed bag at least once a day

You are assigned to remove a fecal impaction. Supplies you will bring to the room include:

Disposable exam gloves

The aquathermia pad must be filled with:

Distilled water

S/S of infection include:

Drainage with an odor

A Nephrostomy tube:

Drains urine from the kidney to the outside of the body

When positioning a patient who has a left leg cast, you should:

Elevate the left foot so it is higher than the left hip

Contraindications for coughing and deep breathing include:

Eyes, nose, or neurologic surgery

A Speci-Cath is commonly used for sputum specimen collection: T/F

False

Odor is generally not a problem for patients with ostomies because the appliance contains the excretions: T/F

False

Patients with tube feedings cannot become dehydrated: T/F

False

The PCT can not contribute to the care plan: T/F

False

When wearing a sterile gown, the area below your waist is considered to be sterile: T/F

False

Signs and Symptoms of a plugged suprapubic catheter, list 4:

Fever Leakage of fluid around site Cloudy output Complaints of pain/ chills HA Sweating Distended bladder Decreased urinary output Sediment in urine Autonomic dysreflexia

Renal colic is:

Flank pain from obstructed urine flow

An NG tube is usually inserted in patients who require tube feeding:

For approximately seven days or less

Reagents are commonly used:

For diagnostic testing

Renal calculi (kidney stones):

Formed from mineral salts collecting around bacteria, blood clots, or other particles

When inserting a nasogastric tube, position the patient in the:

Fowler's position

Skeletal traction is used to treat:

Fractures

A fenestrated drape:

Has a hole in the center

The greatest area of heat loss is from the:

Head

S/S of renal calculi include:

Hematuria

S/S of renal calculi:

Hematuria Urinary frequency and/or urgency Painful elimination Urinary retention Renal colic: pain is sharp and severe in the lower back, waist, and radiates around the body into the groin and testicles Nausea, vomiting, abdominal pain Fever, chills

After anesthesia:

If vital signs are stable patient may be refreshed by: washing hands and face, straightening or changing linens, being given a light rub

List at least five times when you should wash your hands:

In between patient care, after picking up something from the floor, after using the bathroom, after touching an animal (especially a reptile), when performing a sterile procedure

A hydrocolloid or transparent film should not be used:

In the presence of infection

Peritonitis is:

Inflammation of the peritoneum

When assisting a patient with coughing and deep breathing exercises, teach him or her to:

Inhale through the nose

Precautions to take when starting an IV include:

Inserting the needle in the direction of blood flow

You have collected blood in a vacuum tube containing a preservative. You should:

Invert the tube 5 to 8 times

A product that is cytotoxic:

Is harmful to healing tissue

Shaving the operative area is not commonly recommended because:

It increases the risk of infection

A heparin lock is used for:

Keeping the vein patent in case it is needed

The selection of an IV insertion site is affected by the:

Length of time the device will remain in place

A central IV catheter is commonly inserted for:

Long term IV therapy

Sputum is produced by the:

Lungs

The buried bumper syndrome:

May be caused by excessive dressings under the external bumper

Tube position can be checked by:

Measuring the length of the tube from the exit site to the cap and verifying that it is the same each time. Checking the pH of any fluid that flows back from the tube for acidity; it should be alkaline. Aspirated contents should be golden-yellow in color, with a pH of 6 or above. Injecting 2 to 5 mL of air into the tube, while listening for a crackling or swishing sound with a stethoscope. Ensuring that the tube irrigates freely with sterile water.

Wounds heal best in a:

Moist environment

When caring for a patient who wears antiembolism stockings, you should:

Monitor circulation in the patient's toes every 2 to 4 hours

When caring for a patient using an aquathermia blanket, the nursing assistant should:

Monitor the patient for cyanosis or changes in vital signs

When changing a G- tube:

NEVER use a Foley catheter, this may migrate and cause serious complications, including peritonitis.

SIGNS & SYMPTOMS OF HYPERGLYCEMIA:

Nausea, vomiting weakness headache Full, bounding pulse Hot, dry, flushed skin Labored respirations Drowsiness Mental confusion Unconsciousness Sugar in the urine High blood sugar as measured by FSBS

List five rules for using sterile technique:

Never turn your back on the sterile field Never use if wet, torn or damaged Never leave sterile field unattended Never touch the sterile field with anything unsterile Never drop your hands below your waist, below waist is unsterile

Tube feeding formula in an open system bag should hang for:

No more than 4 hours

Gastrostomy tubes are:

Not routinely changed

A straight catheter is used for:

Obtaining a sterile urine specimen

Heat therapy should not be used for patients with:

Paralysis

S/S of fecal impaction include:

Passing liquid stool

The purpose of cultural testing is to identify:

Pathogens in the specimen

Enteral tubes are not used for what:

Patients who are combatative at mealtime

Electronic blood pressure monitoring is contraindicated when:

Patients who weigh less than 100 pounds or under the age of 12

Moist heat:

Penetrates deeper than dry heat

A sitz bath is applied to the:

Perineum

You are removing a dressing that is sticking to the center of the incision. You should:

Pour a small amount of normal saline on the area

A factor that affects wound healing is:

Presence of infection

When starting an IV infusion on a child:

Provide an age-appropriate explanation of the procedure

The rectal tube:

Provides a passage way for flatus to escape

MEASURING GLYCATED HEMOGLOBIN:

Provides a snapshot of the patients diabetic control over the past 2-3 months

When removing a soiled dressing:

Pull the edges of the tape toward the wound

Signs and symptoms of a wound Infection, list 4:

Redness around site Leakage around site (pus) Fever Site is hot

A tepid sponge bath is used to:

Reduce fever

Heat may be used to:

Relieve muscle spasms

The purpose of bladder irrigation is to:

Remove blood clots

When applying heat and cold treatments, the nursing assistant should:

Remove jewelry, buttons, or zippers that may conduct heat or cold

Peritoneal dyalisis:

Requires strict sterile technique

Patients with severe hypothermia should be:

Rewarmed gradually

Mr. Huynh has an IV in his left forearm. His right hand is bandaged because of a hematoma from a previous IV. You must draw blood from this patient. It is safe to draw blood from the:

Right antecubital space

List the five rights of delegation and give a brief description of each:

Right person - the person being delegated has the training to do the delegated task. Right Task- the task is legal for the person to do and within their scope. Right circumstance- the circumstances are right for the person to complete the task. Right Communication- the directions are clearly given to the delegated person. Right supervision- the rn is available to supervise and ask questions if the person needs assistance

Before collecting a sputum specimen, have the patient:

Rinse the mouth with water

Secondary hypothermia is commonly caused by:

Shock and sepsis

The aquathermia blanket:

Should not contact the patient's skin directly

Apply the tourniquet so that the ends of the strap face the:

Shoulder

The patient with a nephrostomy should take a:

Shower

When administrating rectal treatments, you should position the patient in the:

Sim's position

When administering an enema, position the patient in the:

Sims' position

When irrigating a colostomy, position the IV standard:

So the bottom of the bag is even with the patient's shoulder

Systematic infection:

Spreads throughout the body, affecting many systems or organs

Specimens for culture testing are always collected in:

Sterile containers

To test for renal calculi, you should:

Strain all of the patient's urine

Store the hot packs for the hydrocollator:

Submerged in water in the unit

A gastrostomy tube is:

Surgically inserted through the abdominal wall

Specific gravity is a measure of:

The ability of the kidneys to concentrate urine

Glycated hemoglobin is a measurement of:

The blood sugar over a 90-day period of time

The pulse deficit is:

The difference between the apical and radial pulses

Brown spots on the hydrocollator packs suggest that:

The packs are contaminated with a pathogen

before the endotracheal tube is inserted:

The patient must be well oxygenated

The IV catheter is immobilized:

To prevent catheter breakage

A pulse rate of 52 should be reported to the RN: T/F

True

Empathy is a positive quality: T/F

True

Laboratory specimens are transported in a plastic transport bag with a biohazard label: T/F

True

Patients should be encouraged to be as independent as possible, considering their illness or condition: T/F

True

Using a Speci-Cath for urine specimen collection is less traumatic than using a straight catheter: T/F

True

When collecting a stool specimen, ask the patient to void before having a bowel movement: T/F

True

Bleeding in stools suggest the presence of:

Tumors Cancer Other conditions

Complications of suprapubic catheter use include:

UTI

List 4 complications of a suprapubic catheter:

Urine leakage around the catheter Skin Breakdown Bladder stones Blood in urine - hematuria

When transferring blood from a syringe to a blood culture bottle, you should:

Use a sterile transfer device

Care for a patient who are being tube-fed:

Use a syringe that holds 30 mL or more (30mL-60mL): 1) Smaller syringes increases the internal pressure exerted on the tube and stomach. Larger syringes exert less pressure.

When caring for a suprapubic catheter, you should:

Use aseptic technique

The easiest and safest way of drawing blood involves using a:

Vacuum-tube collection system

Avoid starting an IV in the:

Veins on the back of an arm with a rash

When the patient has an indwelling catheter, collect the urine specimen by:

Withdrawing urine from the port with a syringe

When cleansing a wound, always:

Work from the wound outward

A BVM device is:

a bag-valve mask

An indwelling catheter is held in place in the bladder with:

a balloon

Hemothorax:

a collection of blood in the chest cavity

A living will is:

a document that specifies the patient's wishes in the event of cardiac arrest.

Defribillation is:

a method of treatment that uses an electric shock to reverse disorganized activity in the heart during cardiac arrest.

Tracheostomy care is:

a sterile procedure

Tracheostomy:

a surgically created opening into the airway through which a patient breathes.

swab specimen may be collected for:

a test called gram stain

gram stain is:

a type of microbiology or laboratory test that determines whether bacteria are present. It also determines whether bacteria are gram negative or gram positive. The difference between gram negative and gram positive bacteria can be important when determining appropriate treatment for an infection.

Identify the developmental tasks for each of the following life stages: a. Birth to 1 Year b. Toddler c. Preschool d. School Age e. Adolescence f. Young Adulthood g. Middle Adulthood h. Late Adulthood i. Old Age

a. developing trust b. learning boundaries c. learning how to contribute to family d. developing other relationships and friends outside of the home e. developing independence, learning sexuality f. developing intimate relationships g. building relationships, marriages, careers h. accepting lifes choices i. accepting death, making amends with relationships

The ABCs of emergency care stand for:

airway, breathing, circulation

Providing restorative nursing care is important in:

all health care facilities

When wearing a face shield:

always wear a mask

An AED device is:

an autonomic external defibrillator, used only when a patient is unresponsive, not breathing, and pulseless

The BVM device may also be connected to:

an endotracheal tube

Before using the bag-valve mask device insert:

an oral airway

culture and sensitivity specimens must be collected:

antibiotics are administered, if possible

The heart beat occurs:

as a result of ventricular contraction

The handheld computer is used:

as a temporary repository until data is transferred to the mainframe

A patient who returned from surgery several hours ago is smiling and visiting with her family. You should:

ask the patient if she is having pain

A serious condition in which food or fluid enters the lungs is:

aspiration

What does not respond to defibrillation:

asystole

When delivering bolus enteral feeding:

avoid allowing the syringe to empty when adding formula

Signs and symptoms of renal colic include:

back pain that may radiate into the groin

The principles of restorative nursing include:

beginning treatment early, treating the whole person, activity which strengthens the patient

Mrs. Hamerlinck, a catheterized female patient, is in bed, positioned on her side facing the door. Her indwelling catheter should be:

between the legs, on the bed frame on the door side of the bed

Post-resuscitation care is:

care given to a patient who has been successfully resuscitated.

When checking an adult patient to determine if CPR is necessary, check the:

carotid pulse

Reagents are:

caustic, used for testing urine and stool, chemicals that react with body fluids

Before adding anything to the enteral tube, you should:

check placement to ensure the tip is in the stomach

When a catheterized urine specimen is ordered for an incontinent patient who does not have an indwelling catheter, you should:

collect the specimen by inserting a straight catheter

Workplace redesign involves:

combining worker and department responsibilities

When delivering age-appropriate care, the PCT should adjust factors involving:

communication, personal comfort, safety and security

A worker who knows how to safely perform the procedures for which he or she is responsible is:

competent

Pump method:

continuous feeding that is regulated by an electronic pump

Discard used gloves in the:

covered container

Specific gravity values below 1.025 suggest:

dehydration

The exposure control plan:

describes what to do if you contact blood or body fluid

Interdisciplinary teams are composed of workers from:

different disciplines

The ECG/EKG measures the:

electrical activity within the heart

Critical thinking is:

essential to identifying solutions to a problem and solving complex problems

To collect a urine specimen from a child without bladder control, you should:

fasten an adhesive collection bag to the perineum

The most serious form of constipation is:

fecal impaction

Renal colic:

flank pain caused by obstruction to the flow of urine, such as from a stone

If you make an error in electronic patient documentation, you should:

follow facility policies for correcting the record

The patient's brain begins to die after:

four to six minutes without oxygen

Pneumothorax:

free air in the chest cavity outside the lung that passes against the lung, preventing the lung from expanding properly.

Miss Stone is in contact precautions. When entering her room to give a bed bath, the PCT should apply a:

gown and gloves

The first sign that a cognitively impaired, aphasic patient is having pain may be:

grimacing

If a BVM device is applied directly to the patient's face:

he or she is given 1 breath every 5 to 6 seconds or 10 to 12 breaths per minute for adults.

If a BVM device is applied directly to the patient's endotracheal tube or other advanced airway:

he or she is given 1 breath every 6 to 8 seconds, or 8 to 10 breaths per minute.

When the PCT accepts responsibility for a delegated task:

he or she is responsible for his or her own actions

A fingerstick blood sugar reading below 70 suggests:

hypoglycemia

Low body temperature caused by prolonged cold exposure is:

hypothermia

A root cause analysis:

identifies causative or contributing factors associated with untoward events

A sputum culture is collected to:

identify pathogens in the respiratory tract

A midstream urine specimen is collected:

in a sterile container

Turn the pocket mask upside down for:

infant resuscitation

Peritonitis is:

inflammation of the peritoneum, the membranes that line the abdominal cavity; has the potential to become life-threatening.

Singultus (hiccups):

intermittent spasms of the diaphragm

Jejunostomy tube (J-tube):

is a long, small bore tube that is threaded through the GI tract until the tip reaches the small intestine. • Maybe placed through the nose (nasojejunostomy) • Through an incision in the abdominal skin • Used for patients who do not have a stomach • Used for patients with reoccurring formula aspiration

modified barium swallow :

is an x-ray study that shows the patient's potential for aspiration: 1) Monitor a patient's BM after this test is performed, barium will become solid in the colon causing obstruction.

In a negative pressure environment, the air in the room:

is drawn upward into the vents

A PEG tube:

is inserted through the nose and threaded through the esophagus to the stomach

When working in health care, you should:

keep natural nails tips less than 1/4-inch long

The jaw thrust maneuver is used when:

known or suspected neck injury is present

A person who has had a laryngectomy may be called:

laryngectomee

Boundary violations:

lead to inappropriate relationships with patients

Flash sterilization:

may be used only if an instrument is needed quickly

The computer at the nursing station:

may be used to access policies, procedures, and reference information

Which of the following signs or symptoms of problems related to the gastrointestinal system should be reported to the RN:

mucus in the stool

Pathogens can enter the body through:

mucus membranes, non intact skin, the lungs

When the PCT is assigned to perform an activity, he or she:

must report completion of the task when it is done

Do not use the AED on a:

new born infant

Perioperative hypothermia:

occurs primarily as a result of anesthetics

Intradepartmental teams are composed of workers from:

one department

The dorsalis pedis pulse is usually found:

over the instep of the foot

The source is the:

pathogen that causes disease

Migration of a gastric tube may cause:

peritonitis

Discard a used disposable razor in the :

puncture-resistant container

Signs and symptoms of infection may include:

rapid pulse, sweating, hypotension

When removing an indwelling catheter, you pull on the catheter and meet resistance. You should:

reattach the syringe and attempt to withdraw more fluid

Colostomy irrigation is done to:

regulate elimination

An approach on the care plan does not work for the patient. You should:

report the ineffective approach to the RN

The patient who has had a cardiac catheterization:

requires monitoring Q15Minutes until stable

During diastole, the hear is:

resting

The HIPAA rules:

restrict the use and disclosure of patient information

After checking for tube feeding residual, you should:

return the aspirated fluid to the stomach

Streptococcus pyogenes causes many very serious conditions, such as:

rheumatoid fever and kidney damage: rheumatoid fever is a noncontagious acute fever marked by inflammation and pain in the joints. It chiefly affects young people and is caused by a streptococcal infection.

When adding formula to a continuous-drip open system:

rinse the bag and tubing

Before collecting a sputum culture, have the patient:

rinse the mouth with water

As part of daily care, the disk on the gastrostomy tube of a patient with a healed surgical site should be:

rotated 45 degrees

The portal of exit is the:

secretion, excretion, or droplet in which pathogens leave the body

Always wear gloves when:

shaving with a disposable razor

The crash cart is usually checked every:

shift

Infectious diarrhea is commonly spread by:

spores

Mrs. Gonzales is having difficulty breathing when you enter the room. You should:

stay with the patient and call for help

The opening of a colostomy to the outside of the body is the:

stoma

To obtain a catheterized urine specimen, you should use a:

straight catheter

The most effective way to opening the airway is in what position:

supine position

Laryngectomy:

surgical removal of the larynx, with separation of the airway from the mouth, nose, & esophagus.

Gastrostomy tube (G-tube):

surgically inserted through the abdominal wall into the stomach. • Used for long term or permanent use

When you are delivering an electrical shock with an AED:

tell everyone to stand back and stay clear

A specimen is accidentally discarded from a patient's 24-hour urine specimen collection, so the:

test must be discontinued and restarted

Avoid using the contents of a sterile package if:

the paper, inner wrapper is torn

During CPR the hear is squeezed between:

the sternum and the spine

Tracheotomy:

the surgical procedure used to create a tracheostomy

The most common cause of airway obstruction is the:

tongue falling into the back of the throat

The best way to remove spores from your hands is to:

use friction, soap, and running water

Standards of care involve:

using the degree of care or skill that is expected of an excellent worker in a particular circumstance or role

Defibrillation may be successful in reversing:

ventricular fibrillation

What responds to defibrillation:

ventricular fibrillation

Cold exposure preserves the:

vital organs

When collecting a urine specimen from a patient with an indwelling catheter, you should:

withdraw the specimen from the port on the catheter with a syringe

Gastric specimen:

• Checks for the presence of acid in the stomach • A NG tube must be used to obtain the specimen: Patient must be fasting Position the patient in a semi Fowler's position

Post op care to report includes:

• Decreased responsiveness • Change in the level of responsiveness • Increased restlessness • Complaints of thirst • changes in B/P • nausea or vomiting • complaints of pain • active bleeding • coughing or choking difficulty breathing

DETERMINING RESIDUAL STOMACH CONTENTS:

• Elevate the head of the bed 30-45 degrees when withdrawing stomach contents. 1) Feeding is withheld if the amount withdrawn exceeds 100mL or 1 ½ times the amount delivered in 1 hour by continuous administration. 2) If the patient is receiving continuous feeding, stop the feeding 15 minutes before checking for stomach residual. NOTE: A jejunostomy tube is not in the stomach, therefore you cannot check for residual. Doing so increases the risks of complications.

CARING FOR A PATIENT WITH A J-TUBE:

• Food passes from the stomach through the small intestine, where digestion and absorption of nutrients take place. • A Jejunostomy is a surgical opening into the jejunum (small intestine). • The J-tube is used to administer food and fluids directly into the jejunum. • Used for patients who do not have a stomach & for those in which aspiration is a problem. • Requires very slow infusion of formula. • The tube bypasses the protective mechanisms of the stomach, so the risk of infection is slightly higher.

24-hour urine collection:

• Hormones, electrolytes & proteins are secreted in the urine over a 24-hour period • Specimen collection period starts when the patient has an empty bladder • If the specimen is accidently discarded, the test is discontinued

Signs of infection commonly include:

• Increased pain • Erythema - redness and inflammation due to capillary congestion and dilation • Increased bleeding • Tissue in the wound bed becoming more fragile • Discoloration of formerly healthy tissue in the wound bed • Increased drainage • Wound or drainage that develops a foul odor • Fever • Wound that stops healing or show signs of worsening

Endotracheal intubation risk factors:

• Intubation of the esophagus, in which the tube is passed into the esophagus instead of the lungs; this condition is critical because the lungs will not be oxygenated. • Inadvertently passing the endotracheal tube into the right main stem bronchus, so that so that only one lung is ventilated. • Injury to the teeth, lips, mouth, and structures in the throat. • Aspiration. • Apnea, reflex breath holding, reduced O2 delivery. • Laryngeal edema. • Oral or nasal erosion; similar to a pressure ulcer. • Oral or nasal necrosis; similar to that seen with a pressure ulcer. • Bleeding. • Hypoxia; low oxygenated blood. Bradycardia; slow pulse.

Sputum culture:

• Is best collected early in the morning, if possible. This will capture secretions that have accumulated overnight. • Rinse the mouth with water before collecting the specimen. • If possible, obtain 15mL of fluid.

Tracheostomy care involves:

• Keep the stoma & cannula clean & free from obstruction. • Prevent skin irritation and breakdown. • Prevent water & solid foreign matter from entering the lungs. • Prevent infection. • Like oropharyngeal & nasopharyngeal suctioning, pressures in the suction machine should not be <80 or >120.

Caring for a patient who is on ventilator involves:

• Make sure that the alarm is on at all times. It should never be turned off. Respond to alarms immediately. Remember, if an alarm sounds, check the patient first, not the machine. • Provide frequent oral and nasal care. Monitor the mucous membranes for signs of pressure, irritation, and breakdown from the breathing apparatus. • Observe for changes in respiratory rate and depth, shortness of breath, and use of accessory muscles in breathing. • When monitoring V/S of patients who are using mechanical ventilation, count spontaneous respirations as well as ventilator delivered breaths. • Check for tube displacement or misplacement each time you are in the room. The endotracheal tube is usually marked at the lips, teeth, or nares, so you can see if the tube has moved. • Make sure that the endotracheal tube is taped securely. • Visually inspect the chest. If it does not appear symmetrically upon breathing, inform the RN. • Monitor the patient regularly for complaint of pain, and report to the RN. • Elevate the head of the bed 60 - 90 degrees, or as directed. • Remember that elevation of the head of the bed increases the risk of skin breakdown. Reposition the patient Q2H or more often. Provide preventative skin care with lotion. Apply therapeutic mattress, if ordered. • Elevate the heels of the surface of the bed to prevent pressure ulcers. • Suction if permitted, using a sterile technique. • Condensation in the ventilator tubing will cause resistance to air flow and increase the risk of aspiration. Condensate must be drained into a collection trap, or the patient must be disconnected from the ventilator long enough to empty the tubing. Inform the RN if condensation forms. Do not attempt to perform this procedure unless you have been taught to do so, and are permitted to disassemble the ventilator parts. Never empty condensation in the ventilation tubing backward into the humidifier or in a way that causes you to get sprayed in the face with contaminated fluid. • Use disposable saline irrigation units to rinse in - line suction. • Make sure adequate sterile supplies are quickly available in the room. • Monitor the patient for constipation. • Provide active and passive ROM, according to care plan. Monitor the patient's tolerance to the ventilator by checking pulse oximetry, V/S, cardiac monitor, anxiety, ability to sleep, and mental status. Suction as needed and if permitted.

Caring for a Pt who has ET tube involves:

• Monitoring the Pt frequently & anticipating his/her needs. • Keeping HOB I semi-fowler's position as directed. • Keeping the Pt head turned to the side if an oral nasal airway is used; helps prevent aspiration. • Suctioning oral secretions. Avoid suctioning ET tube. • Inserting oropharyngeal or nasopharyngeal airway & removing the airway once each shift for cleaning. • Providing oral & nasal care. • Keeping the lips and mucous membranes moist. • Repositioning the Pt Q2hrs or more often, if indicated. • Monitoring restraints. • Monitoring bony prominences for S/S of breakdown. • Monitoring tube insertion site for S/S of irritation, redness, and breakdown. • Monitoring V/S + capillary refill. • Monitoring signs of distress. • Reassuring the Pt & family. Developing means of communication with the Pt, such as using a magic slate, or by writing.

What do you report to the RN on tracheostomy suctioning:

• Patients reaction to & tolerance of the procedure • Change in V/S • Change in patient's color • Change in the pulse oximeter or cardiac monitor • Color & character of secretions o Thin, white, translucent, slightly sticky • Report: thick secretions, yellow, green, brown, or red sputum, red streaks in sputum.

Endotracheal intubation advantages:

• Provides a means of delivering 100% O2 directly to the lungs. • Provides method for delivering positive pressure ventilation in a code or other emergency in which the patient requires ventilation assistance. • Protects the airway in patients who are at risk for aspiration. • Maintains a patent airway in patients who develop an airway obstruction, despite the presence of an oral or nasal airway. • Maintains a patent airway in patients with burns, inhalation injuries, or ingestion of caustic substances that cause swelling in the throat or lower airway. • Provides a pathway through which the health care professional can suction the lungs. Does not cause gastric distention (a condition in which the stomach fills with air) during artificial ventilation.

Post op vital signs include:

• Take vital signs upon the patient's arrival on the unit every 15 minutes for 4 readings • Count the pulse and respirations for one whole minute • Every 15 minutes for 1 hour • If stable every 30 minutes for 1 hour • If patient continues on being stable every 4 hours for 24 hours Check the pulse distal to the operative site

Culture and sensitivity testing:

• The culture identifies the specific pathogen & the sensitivity part of the test shows which antibiotic will best eradicate the pathogen

Collecting a sterile urine specimen from an indwelling catheter:

• The inside of the closed catheter system is sterile • The system is not opened when a urine specimen is collected • The catheter is clamped to collect urine for 10 to 15 minutes • Urine is withdrawn from a collecting port on the catheter using a needle and syringe

Steps in collecting a wound culture include:

• Thoroughly rinse wound with sterile saline before culturing • Do not use pus to culture • Do not swab over hard eschar (a dry, dark scab or falling away of dead skin) • Use sterile Ca Alginate swab or rayon (not cotton) swab • Rotate swab • Swab wound edges and 10-pt coverage

The three enemies of specimen collection are:

• Time (in terms of transporting the specimen) • Temperature (avoid extremes) • Desiccation (do not let the specimen dry out)

Intermittent or continuous drip:

• formula drips into the tube by gravity from an administration set that hangs on IV standard next to the bed.

Bolus method:

• pouring formula into the tube through a syringe (allow the formula to flow in by gravity).