Exam 3

What can you use a central line for?

-BLOOD DRAWS -med admin -chemotherapy

What are the different types of CVC?

-Nontunneled central lines (most common): placed at bedsides, not recommended for long term use, mostly used in emergent situations -Tunneled central lines -PICC: placed in peripheral vein, can be placed by a trained RN, and can be used for long term care -Ports: accessed with the use of a special needle that is bent at 90 degrees

Describe how you will hang TPN and lipids

-The special IV filter used to hang TPN prevents particles from the amino acids from entering the pt. It should be places on the end of the TPN tubing, the lipids go below the filter. -The lipids line should be inserted into the port closest to the pt and the lowest port on the TPN line (it does not go through the TPN filter so it goes below it) -The two lines "Y" together and are infused into the central line

Why is a chest tube connected to suction or set to gravity drain?

-To remove air, fluid, blood, pus -To restore proper negative pressure in pleural space/cavity -Reinflate collapsed lung -Prevent blood accumulation following chest surgery

Nursing Interventions to perform on a patient who is receiving TPN and Lipids

-daily weights -strict I's + O's -Q6H GLUCOSE CHECKS with weight based insulin protocol if needed -If glucose concentration is >10% or amino acids are >4%, then infuse into central vein -Especially in diabetic pmts, be aware that insulin may be added to each TPN bad to better regulate glucose levels -CHANGE IV LINE AND BAG PER POLUCY, TYPICALLY Q24H -Use special IV filter to hang TPN -They are high alert medications that require 2 nurse's signatures -Always administer each. on a separate IV pump -If the bag empties before arrival of new bag from pharmacy, D10 should be hung and pharmacy notified

What would be an indication for CVC insertion?

-long term antibiotics -casutic medications -chemotherapy -large volumes of fluid -frequent blood test labs -TPN/lipids -Accurate monitoring of internal pressures and VS -inadequate vascular access

Nursing Interventions for CVC

-proper hand hygiene prior to handling CVC -STERILE technique with all dressing changes -scrub the hub for 30 secs with alcohol or per policy -Flush CVC with 10 mL NS before and after use -Biopatch and hub cap change with each dressing change -If unable to flush catheter or unable to get return blood flow, contact HCP and do NOT use. May require a clotting medication called Alteplase

List possible side effects of TPN and Lipid therapy

1.) FLUID VOLUME OVERLOAD or pulmonary edema 2.) HYPER OR HYPOGLYCEMIA 3.) INFECTION 4.) Embolism 5.) Electrolyte imbalances 6.) Lipids might cause nausea, dizziness, or vertigo 7.) Refeeding syndrome where their is rapid referring after a period of malnutrition thus causing electrolyte shift

What is the definition of illness?

A state in which the client's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished.

What is the definition of health?

A state of complete physical, mental, and social well being & not just the absence of disease or infirmity

Suicidal assessment

As a nurse, be comfortable in asking suicidal thought, plan, and intent. Don't be bashful in asking the question. Just asking a question does not plant the idea of suicide in somebody's head

Culture in regards to health/wellness/illness

As nurses, we have to be respectful of decisions Be culturally sensitive Understand how culture influences decisions

Define the ethical principles

Autonomy - right of pt to make their own decisions Veracity - be truthful and honest with pts Nonmaleficience - action needs to be weighed against benefits, consequences, and risks Beneficence - act in the best way for the pt Justice Utility - benefit maximized with cost minimized Fidelity - loyalty Paternalism - HCP makes decision with explicit consent from pt Confidentiality Accountability

What is rationed care?

Because of what is going on, their must be allocation of resources...care isn't being finished or is being withheld. ex: ventilators are running out for covid pts and we must decide who is going to get one and who is not

monoamine oxidase inhibitors (MAOIs)

Can cause hypertensive crisis or serotonin syndrome Works extremely well but used infrequently their are lots of restrictions and life-threatening complications NO aged cheese, cured meats, deli meats, fermented cabbage, sourcrout, no leftovers, nothing past the prime date. ONLY fresh foods because you can't have any tyramine

How is A-fib and A-flutter treated?

Cardioversion Beta-Blockers Calcium Channel Blockers (Dialtizem) Digoxin Anti-platelets and anti-coagulants

Who makes up ethics committee?

Collaborative team of nurses, physicians, etc.

Rules of Delegation

Delegate a task, not the responsibility When you delegate to an LPN, do it with stable pts that ALL nurses would be familiar with. EX: insulin administration When you don't know the skill level of the person you are delegating to, ask them to demonstrate the skill for you, rather than asking them if they can do it. EX: "Why don't we go into this room and you show me how to put on a pair of sterile gloves. In fact, we will do it together. You watch me and I'll watch you."

What is the basic content inside TPN?

Dextrose Amino Acids Vitamins Electrolytes Minerals Trace Elements

Describe therapeutic boundaries related to the nursing code of ethics

Don't accept gifts from clients Don't date our clients

How should the nurse support pts in their decision making process?

Don't give out advice but offer feedback so that we can help our pts make the best decision. Then, support it and don't go behind their backs to finagle or change their mind/decision.

What is the RN's role in assisting somebody else insert a line?

Ensure maximal barrier for sterility

What do you do if a chest tube gets dislodged from the pt?

Grab the petroleum soaked gauze and cover the sight Check lung sounds and O2 sats Call HCP

What is serotonin syndrome?

Group of symptoms following the use of some serotonergic medication. Symptoms include shivering, diarrhea, seizures, muscle rigidity, and death

Are bubbles normal in a chest tube system?

In a wet system, gentle bubbling is normal in the suction chamber but NOT normal in the water seal chamber Bubbles indicates an air leak

What is the difference between a wet and a dry chest tube system?

In a wet system, the suction chamber is based on the level of water In a dry system, suction is based on the dial that we turn and is ensured that the bellow meets the arrow

What are some possible complications associated with CVC's?

Infection Catheter occlusions Embolism Thombosis

Describe major depressive disorder

Lasts at least 2 weeks Untreated episode of depression can last weeks, months, or years but most clear in about 6 months

How will a patient with a pneymothorax or hemothorax present?

Pleuritic chest pain SOB Anxiety Decreased O2 sat & cyanosis Tracheal deviation Tachycardia Hypotension

What do you do if a chest tube becomes disconnected from the tubing?

Pour sterile water in a cup and place the chest tube in it to create a water seal chamber Clean the tubing with alcohol if not visibly dirty If visibly dirty, order a new chest tube system

What should be included in SBAR report?

Provide accurate information to provide in safe pt care Situation Background Assessment Recommendation

What is the nurse's primary concern with pts experiencing mood and affect problems?

SAFETY

What are s/sx of depressive disorder?

Sad mood Lack of interest Change in eating habits Insomnia Hypersomnia

True or false. Depression is most associated with suicide.

TRUE

True or false. Clients with depression often exhibit anhedonia.

TRUE Anhedonia refers to the loss of any sense of pleasure from activities that a person formerly enjoyed. This is a manifestation of depression.

What is the definition of wellness?

The state of well-being that encompasses self responsibility, dynamic growth, nutrition, physical fitness, emotional health, preventative healthcare, & the whole being of the individual

What is the role of the ethics committee?

They offer recommendations and help the family and staff work through the situation. It is NOT the role of the committee to make a decision.

What is tidaling?

Tidaling is when the ball moves up and down a little. This is normal and expected when pt breathes in.

How and why do you use Kelly clamps on a chest tube?

Use Kelly clamps to clamp the tubing (only for a few seconds) in order to find out if their is a leak somewhere throughout the tubing

Aytpical Antidepressants

Used when their is a poor response to SSRIs

Why are we involved in evidence-based practice?

We engage into nursing research and evidence-based practice to expand the body of knowledge Nursing research helps to improve ways to promote and maintain health. The rationale for evidence-based practice is to ensure quality care

Caring for a pt with anxiety

When a pt is treated for anxiety, it's because they do not have adequate coping mechanisms. The anti-anxiety meds just help the pt to relax and improve their focus. These meds are not for long-term care because they can become addictive

A nurse is teaching a client who has a new ileostomy. The client states, "I'd rather be dead than have to live with this all my life." Which of the following responses should the nurse make? a. "You appear upset. Would you like to talk?" b. "I'll ask the provider to prescribe a medication to help you relax." c. "there's no reason to feel like that. Things will get better." d. "I am sorry that you are going through this. I would feel the same way."

a. "You appear upset. Would you like to talk?"

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? a. assume an open position b. sit upright and lean back into the chair c. avoid direct eye contact until the client initiates it d. sit next to the client

a. assume an open position -Sit with arms and legs uncrosses, lean toward the client, establish direct eye contact, and face the client.

A nurse is caring for an adolescent client who is overweight. The adolescent tells the nurse that classmates tease him about his weight. Which of the following responses should the nurse make? a. "You shouldn't worry about what other people say." b. "Tell me how you feel when your classmates tease you." c. "Your friends will learn to like you for who you are inside, not what you look like." d."It is important to begin to eat healthier so you can look the way you want to look."

b. "Tell me how you feel when your classmates tease you."

A nurse is making morning rounds when a client says "I almost died last night." Which of the following responses should the nurse make? a. "If I were you, I would tell your provider about this." b/ "I am sure many people get those dreams when they are away from home." c. "That must have been frightening. Tell me more about it." d. "Why would you dream about something like that?"

c. "That must have been frightening. Tell me more about it."

The nurse is caring for a patient who is receiving TPN and lipid therapy. How often will the tubing for the TPN and lipids be changed? a. every 82 hours b. every 12 hours c. every 24 hours d. every 96 hours

c. every 24 hours

A nurse is caring for an adolescent who has a positive hCG test. She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following responses should the nurse make? a. "Do you think you might terminate the pregnancy?" b. "Give them a chance. Your parents will understand." c. "You must tell your parents as soon as possible." d. "You seem frightened to tell your parents."

d. "You seem frightened to tell your parents."

A nurse at a skilled nursing facility is admitting a client who has Alzheimer's disease. While speaking with the nurse, the client's partner begins to cry and says "I never thought it would come to this. I feel so guilty about bringing my husband here." Which of the following responses should the nurse offer? a. "if he understood what was happening, I'm sure he would forgive me." b. "we will take good care of your husband here." c. "Admitting your husband was the right decision." d. "this has been a difficult time for you."

d. "this has been a difficult time for you."

A nurse is caring for a client in premature labor who is not responding to tocolytic therapy. The client says to the nurse, "I am so worried about my baby." Which of the following responses should the nurse make? a. "The hospital has a newborn intensive care unit." b. "do you want me to call someone to talk with you?' c. "this happens all the time, and the baby is often born healthy." d. "you are very frightened for your baby."

d. "you are very frightened for your baby."

Important things to remember when caring for a pt with a chest tube

-Always assess the pt's respiratory status before assessing equipment or site -Daily chest x-ray will be ordered -Never clamp a chest tube for more than a few seconds -Keep a small bottle of sterile water at bedside in case of emergency -Keep clamps and petroleum gauze dressing at bedside -Bubbling in the water seal chamber indicates an air leak -The usual ordered amount of suction is -20 cc H2O -Do not pin the chest tube drainage tubing to the bedding or the pt's gown

What is the RN's role prior to chest tube insertion?

-Check the patient ID and confirm that informed consent has been obtained -Assess pt's understanding of procedure and current labs/meds -Help with client positioning -Gather sterile thoracotomy tray with equipment & supplies -Administer prophylactic pain meds, antibiotics, and local anesthetic -Set up oxygen, wall suction, and chest drainage system

Most common sites for CVCs

-IJ and subclavian: best choices for decreased risk of infection -Femoral: last resorts due to high risk of infection -PICCS are commonly placed in basilic, cephalic, and brachial

How to assess a central line?

-Is there any redness, swelling, heat, or drainage -If it is NOT bloody or serous fluid, we are concerned about infection -Is the dressing soiled?

What is the RN's role pos chest tube insertion?

-Maintain potency (no kinks, occlusions, dependent loops) -Monitor & measure output -Safety: prevent tube dislodgment or system knock overs -Maintain prescribed level of suction -Monitor for complications

How do you care for a CVC?

-Maintain sterility -Dressing changes as indicated by status/policy -Maintain latency -Verify placement via measurements -Ensure stability of placement -Keep connections tightly closed -Monitoring for complications or leaking

Why would a patient be administered TPN and/or lipids?

-Pt is getting GI surgery which requires bowel rest -Chewing/or swallowing disorder -Inflammatory bowel disorder -Adjunct nutritional support for burn pt or anorexic pt -TPN isa bridge to more definitive care like a feeding tube unless pt improves and can support own nutritional needs

What is a hypertensive crisis?

A severe increase in blood pressure that can lead to a stroke. Extremely high blood pressure — a systolic > or = 180 or a diastolic > or = 120 mm Hg or higher damages blood vessels. They become inflamed and may leak fluid or blood. As a result, the heart may not be able to pump blood effectively.

What does A-fib look like on an EKG versus A -flutter

A-fib Rhythm irregular (R to R is different) Absent P-waves F-waves can have a ratio (2:1, 3:1, 4:1) A-flutter R to R is regular No P-waves, F waves that are 'saw toothed'

What are strategies to prevent moral distress for nurses?

Educational interventions -increase confidence & reduce fear Provide tools for decision making - ethical frameworks & principles Improve the environment nurses work in - ethics committees, multidisciplinary ethical rounds, formal debriefings to discuss morally charged events, policy development for futile care Coping strategies - mindfulness, self-reflection, professional networking, journaling

What is the RN's responsibility in clinical research?

Ensure the pt understands what they are participating in. It had nothing to do with consent forms, it deals with teaching. Does the pt understand? Do they have questions? If you don't have an answer for them, go get somebody who can answer them.

What is included in evidence-based practice?

It includes clinical judgement (how you decide what you are going to do in a situation) with book knowledge, scientific practice, common knowledge, and the history of what you have seen and experienced as a nurse. evidence-based practice is relevant scientific evidence

What should the RN do with healthcare information?

Maintain HIPPA Dont='t give out information to neighbors, clergy, etc...send them to the pt directly or the spokesperson for the family.

Describe electroconvulsion therapy (ECT)

Medical treatment most commonly used in pts with severe major depression or bipolar disorder that has not responded to other treatments. It involves a brief electrical stimulation of the brain causing a grand Mal seizure while the pt is under anesthesia It works very well It is safe and effective for pregnant women and the elderly The longer the seizure, the better outcome Procedure takes about 20 minutes Pt must undergo a cardiac stress test prior Very expensive

Selective Serotonin Reuptake Inhibitors (SSRIs)

Newest class of drugs that are effective for most people Serotonin stays in the synapses to be used Extremely safe: it is hard to complete a suicide or overdose on this drug In 7 to 10 days, pt will start to feel better Ex: Fluoxetine, Paroxetine, Citalopram

Risk factors for developing A-fib/A-flutter

Older adults obesity and diabetes HTN valvular heart disease HF Obstructive sleep apnea cardiac ischemia cardiac inflammatory disease ETOH post-op cardiac surgery hyperthyroidism myocardial hypertrophy

Tricylic Antidepressants

Oldest group of antidepressants Takes 10 to 14 days of treatment to see improvement Takes 6 weeks for med to take full effect Medication costs less Overdose and suicide can occur on this drug Anticholinergic SE: BPH, glaucoma, "dry people up" Ex: Dioxepine, Notriptyline

What are some S/SX of A-fib/A-flutter?

Palpitations & Chest pain irregular pulses fatigue & weakness SOB w/ anxiety Dyspnea on exertion Hypotension from decreased cardiac output Thombi - stroke

Interventions to practice for a pt with major depressive disorder

Provide for safety through suicide precautions Promote a therapeutic relationship through therapeutic communication Promote ADLs and physical care Managing meds Client and family teaching

Examples of ethical dilemmas

Providing unnecessary treatment Quality of life/inadequate pain relief HCP giving false hope to client and family - client right to know Hastening the dying process Disregarding the client's wishes Incompetent caregivers

What is the best type of treatment in pts with major depressive disorder or other mood disorders?

Psychotherapy combined with medication. Meds help the brain to function while therapy helps with coping strategies

Examples of evidence-based practice

Putting the HOB up when a pt is having trouble breathing Turning pts q2h to prevent skin breakdown

How should the nurse care for a visually impaired pt?

Read the consent to them and ask if they have any questions Have a witness in the room like a family member or another nurse You can remain in the room with them and have a family member read the consent Allow for extra time on questions

A nurse is providing teaching to a client who has anxiety and a new prescription for diazepam. Which of the following statements should the nurse make? a. "Feelings of sedation should resolve in about 1 week." b. "There is no risk of physical dependence with this medication." c. "you can increase the dose when you feel especially anxious." d. "it will take several months for you to feel the maximum benefit of the medication."

a. "Feelings of sedation should resolve in about 1 week." -Adverse effects of diazepam and other benzodiazepines are sedation and psychomotor flowering. The nurse should inform the client these side effects should subside in 7 to 10 days. -Long term use of diazepam and Benzes makes the pt at risk for physical dependence. -The onset of diazepam is immediate.

A home health nurse is assessing a toddler who is scheduled to begin receiving hospice care for a terminal illness. The child's parent tells the nurse, "This is all my fault, and I wish I could trade places with my child." Which of the following responses should the nurse make? a. "Tell me more about what you are feeling." b. "I understand how you are feeling." c. "Let's talk about hospice care for your child." d. "try to focus on more positive things."

a. "Tell me more about what you are feeling."

What will the nurse incorporate into the POC for the pt who is receiving TPN and lipid therapy? a. daily weights and accurate I&O's b. neuromuscular assessment q4h c. active + passive ROM exercise d. pt education about IS

a. daily weights and accurate I&O's

A nurse is speaking with a client whose partner was killed unexpectedly. The client states "I just don't know what to do now." Which of the following actions should the nurse take? a. talk to the client about available community resources b. distract the client by discussing events not related to the crisis c. reassure the client that he will feel better soon d. give the client advice about what to do during the next few days

a. talk to the client about available community resources

A nurse is caring for a client who is receiving continuous cardiac monitoring. Which of the following medications should the nurse anticipate administering to treat atrial fibrillation? a. atropine b. diltiazem c. epinephrine d. phenytoin

b. diltiazem (CCB)

A nurse is caring for a client who has no family members present and is upset by the recent news that a current treatment has not been effective. The nurse states, "I am going to stay with you until your family is able to get here." Which of the following communication techniques is the nurse using? a. presenting reality b. offering self c. seeking clarification d. planning

b. offering self

A nurse on a medical-surgical unit is talking with a client who pauses while discussing his feelings about being in the facility. The nurse replies, "please go on." Which of the following communication techniques is the nurse using? a. reflecting b. providing a general lead c. focusing d. seeking clarification

b. providing a general lead

A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize when speaking with the client? a. "Do you have any close friends?" b. "Can you describe how you feel about what's happening?" c. "Have you thought about hurting yourself?" d. "How are you dealing with being away from your family?"

c. "Have you thought about hurting yourself?"

A nurse in a mental health clinic is beginning a counseling session with a client who is having difficulties in a personal relationship. The client states that she does not want to talk at all today. Which of the following responses should the nurse make? a. "Why don't you want to talk today? We have talked several times before." b. "I think you should take a moment to collect your thoughts. Then, you need to talk." c. "How about I just spend some time with you instead? We don't have to talk." d. "I don't believe that you don't want to talk to me. You know it can be helpful."

c. "How about I just spend some time with you instead? We don't have to talk."

A nurse is teaching a client who has a prescription for a tricuoic antidepressant. Which of the following instructions should the nurse include in the teaching? a. "Take this medication within 1 hour of waking each morning." b. "Limit alcohol to 2 drinks per week while taking this medication." c. "It can take 6 weeks to achieve full therapeutic effect of this medication." d. "Stop taking the medication if you experience dizziness."

c. "It can take 6 weeks to achieve full therapeutic effect of this medication." -Tell the client to take the tricyclic antidepressant each day at bedtime to decrease sleepiness during the day. -Instruct client to avoid drinking ANY alcohol which taking a tricyclic antidepressant -A tricyclic antidepressant can cause dizziness during initial treatment. This is expected to diminish after first few weeks of taking the med

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight-management program. the nurse determines that the client gained 3 lbs in the past week. Which of the following statements should the nurse make? a. "You should try a little harder to stick to your diet." b. "Why do you think you've gained 3 lb this week?" c. "were there any issues last week that kept you from focusing on your diet?" d. "You should put this week behind you and adhere to your diet from now on."

c. "were there any issues last week that kept you from focusing on your diet?"