ATI-FAQs

How long can an IV catheter stay in place?

According to guidelines from the Centers for Disease Control and Prevention (CDC), as long as there are no signs or symptoms of infiltration or phlebitis or concerns about possible contamination, a peripheral venous catheter can remain in place in an adult for 72 to 96 hours.

What medications can I give through a nasogastric tube?

Administer liquid forms of medications, such as suspensions, elixirs, or solutions, via the nasogastric route whenever possible to prevent tube obstruction. Dissolve powders and tablets that are approved to be crushed in 15 mL of sterile water and administer them separately, flushing with 15 mL of sterile water between each medication. Break apart capsules containing powder and dissolve the powdered medication according to manufacturer's instructions. Medications that cannot be crushed include buccal, sublingual, sustained-released medications, and enteric-coated medications. Whole medications or medications that are not completely dissolved before administration increase the risk of tube obstruction. Medications that tend to solidify, such as hydrophilic (water-attracting) gels (e.g., psyllium-based bulk laxatives) increase the risk of clogging the tube. Flush with 15 mL of sterile water after giving all medications.

Why is it so important to get all the air out of an infusion set and any add on devices?

Air embolism is a potential complication of any intravenous therapy. The nitrogen that comprises the majority of the air dissolves fairly quickly in the patient's blood, but large amounts might not dissolve quickly enough to avoid embolism.

Do I have to wear gloves to administer an injection?

Although the policy might vary with the facility, you are taking a risk if you do not wear gloves when giving an injection. The latest Centers for Disease Control and Prevention (CDC) guidelines for preventing the transmission of infectious agents recommend wearing gloves whenever you anticipate "direct contact with blood or body fluids, mucous membranes, nonintact skin, and other potentially infectious material." Since there is no way to be sure that you won't encounter blood, and you know you will encounter nonintact skin with intramuscular, subcutaneous, and intradermal injections, you are protecting yourself and your patient by wearing gloves when you give an injection. The Occupational Safety and Health Administration (OSHA) concurs; its standards for bloodborne pathogens similarly recommend wearing gloves when "it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin." OSHA had previously stated that gloves are not required "when giving an injection as long as hand contact with blood or other potentially infectious materials is not reasonably anticipated," but you cannot possibly predict with 100% accuracy that you will not have contact with blood. The safest thing to do is to anticipate the possibility of blood contact every time you pierce a patient's skin and therefore wear gloves.

What are the common signs and symptoms of UTI?

An elevated white blood cell count, urine with a pungent odor, increased sediment in the urine, confusion or alteration in mental status, a change in urination pattern, and fever can all indicate UTI. It has been found that using reagent strips (commonly called urine dipsticks) is not effective in diagnosing a UTI; laboratory urinalysis and culture and sensitivity must confirm the diagnosis. A culture involves growing a sample of the bacteria found in the urine and seeing which common antibiotics are effective in killing the bacteria. This information is very helpful for effective antibiotic treatment of UTI. Escherichia coli is the bacterium that most often causes UTI.

What impact does the use of abbreviations have on medication errors?

One of the major causes of medication errors the Joint Commission has identified is the continuing use of potentially dangerous abbreviations and dosage expressions. Contributing factors are illegible or confusing handwriting and failure of healthcare team members to communicate effectively and clearly with one another. Examples of problematic abbreviations include: -The use of "U" for "units"; the "U" can look like a zero when handwritten. -Using "µ" instead of "mcg" for "micrograms"; the "µ" symbol can look like an "m." -The use of trailing zeros (2.0) or a leading decimal point without a zero (.2); if the decimal point is not clearly visible, drastic dosing errors can result.

I am having difficulty obtaining an adequate fingerstick sample for blood glucose testing for a patient who has diabetes. What should I do?

Since lancets generally come in different sizes for penetrating the skin to different depths, a larger lancet might help. Poor peripheral perfusion can also reduce the availability of blood. Ask the patient to dangle her hands to allow blood to flow into the fingers. Also, ask her to rub her hands together to warm them, as that might promote blood flow. Another option is to wrap the finger in a warm cloth prior to the puncture. Check the skin on her fingers. It might be calloused from repeated fingersticks. If so, try another site, such as the palm of her hand. Do not milk the finger before a fingerstick, though, as this can alter the readings.

What is a major source of microbial contamination in the surgical environment?

Skin is a major source of microbial contamination. Although you cannot make your skin sterile, you can make it surgically clean by reducing the number of micro-organisms on it by cleaning your nails, hands, and forearms preoperatively (surgical hand asepsis). This process removes dirt, skin oil, and transient micro-organisms; reduces the microbial count to a minimum; and leaves an antimicrobial residue on your skin to prevent the regrowth of microbes for hours.

What if my patient's primary IV or medication infusion cannot be stopped to administer PRN or scheduled IV bolus (push) medication?

Some IV medication and fluid infusions cannot be interrupted. In that case, start IV access at another site and administer the medication using the new IV lock.

Which part of the gown is considered sterile?

Sterile gowns are considered sterile in the front from the shoulder to the level of the sterile field and from 2 inches above the elbow to the cuff. Because the cuff tends to collect moisture, it is not an effective bacterial barrier and is not considered sterile. That is why you must cover the cuffs with sterile gloves. Other areas of the gown that are not considered sterile are the neckline, the shoulders, the areas under the arms, and the back of the gown.

Why must I label IV bags instead of just writing directly on the bag?

Writing on a flexible plastic IV bag could puncture it. Furthermore, the ink from the pen could seep through the plastic and contaminate the solution.

Are ophthalmic medications considered sterile?

Yes, ophthalmic medications are considered sterile. To keep them sterile, avoid touching the tip of the container, applicator, or dropper to any surface, including any of the patient's eye structures. That would increase the risk of contamination of the medication, not to mention injury to the patient. Instruct patients not to share ophthalmic medications with other family members (because the risk of transmission of infection is high) and to discard any remaining medications after they complete the prescribed course of treatment.

Why can't I crush enteric-coated or sustained-release medications before giving them to a patient who can't swallow pills?

Crushing an enteric-coated medication releases irritating components of the medication that subsequently come into contact with the oral or gastric mucosa, causing mucositis or gastric irritation. Sustained-release medications, if crushed, release all of the medication to be absorbed at once, resulting in higher-than-expected initial levels of the medication and a shorter-than-anticipated duration of action.

How long can infusion sets be used?

For IV tubing sets, the Infusion Nursing Society recommends the following: -Replace tubing used to infuse: -blood or blood products every 4 hours. -continuous IV lipids every 24 hours. -intermittent infusion every 24 hours because of the potential of contamination from opening the IV system. -Replace other tubing every 96 hours.-Always maintain sterility-Replace tubing used for: -intermittent infusions every 24 hours and solutions that are more conducive to the growth of micro-organisms, including parenteral nutrition, more frequently.

How high above the IV site should I hang the IV bag?

For an optimal flow rate, position the IV bag about 36 inches above the IV site.

A nursing assistant collected a clean-catch urine specimen from my patient for laboratory urinalysis. By the time I got to the specimen to send it, an hour had passed since it was collected. Can I still send this sample to the laboratory?

Fresh urine samples for laboratory analysis should be placed immediately into a sterile container for transport. They should be kept on ice and transported to the laboratory within 2 hours of collection. Urine that is standing unrefrigerated can become more alkaline, and that can encourage bacterial growth and reduce the validity of the results. This sample was not placed on ice, so you should discard it and start over.

My patient has a nasogastric feeding tube in place. What should the pH be if the tube is placed correctly in the stomach?

Gastric pH should be more acidic than secretions from other areas of the body, which are generally below 5.5. By checking gastric secretions, you can verify both the placement of the nasogastric (NG) tube and the relative rate of gastric emptying (by measuring the residual volume of gastric contents). NG tube placement is initially confirmed by chest x-ray; this is the most reliable method for checking placement. Second only to x-ray, pH testing is considered a reliable method for confirming NG tube placement in the stomach.

Why is it no longer accepted practice to store items such as oral thermometers in a disinfectant solution?

Germs can contaminate the disinfectant and then contaminate the items being soaked in it. Always store items "dry."

What strategies should I use to help keep patients from developing UTIs?

Give appropriate and thorough perineal care (hygiene of the genital region), assess equipment carefully to ensure a closed system, and intervene to prevent prolonged catheter use. Some studies speculate that catheter-related UTI accounts for up to 40% of hospital-acquired infections.

How far can a virus laden droplet travel and still be a potential source of infection?

It can travel up to 3 feet in any direction and still be infectious.

What should I do differently if my patient is very thin?

It is important to consider your patient's body weight and amount of subcutaneous fatty tissue when selecting the needle and choosing the site and angle of insertion for subcutaneous or intramuscular injections. When giving a subcutaneous injection to patients who have very little fat, use the upper abdomen. When giving intramuscular injections to older adult patients or those who are very thin, use a smaller size needle.

Why must I inspect an IV catheter when I remove it?

It is possible for an IV catheter to be damaged during insertion or removal. It can then break off and become an embolism. The catheter can also be damaged if the needle is reinserted into the catheter during IV insertion or if excessive pressure or an improper angle is used during removal of an IV catheter. Also, any signs or symptoms of infection at the catheter site at the time of removal could warrant culture of the catheter tip.

What indications of urinary tract infection should I check for before I do a urine reagent strip test or request a urinalysis order from the provider?

Key features indicating a urinary tract infection are frequent urination, urgency, hesitancy or difficulty initiating a stream, retention, feeling of incomplete emptying, burning or pain with urination, low-back or flank pain, hematuria (blood in the urine), pyuria, foul-smelling urine, cloudy urine, fever, incontinence, and confusion or behavioral changes. Keep in mind, however, that many urinary tract infections are initially asymptomatic.

My patient's provider ordered a wound culture, but the patient has multiple wounds that are quite large. How do I decide where to collect the specimen from?

Large wounds and multiple wounds call for multiple samples. Never use the same swab on more than one location. Avoid swabbing a wound's edges because they may be contaminated with external skin flora. Swabbing the center of the wound, parts of the wound with different appearances, and individual wounds will help create the clearest clinical picture in the laboratory.

Why do I have to let cleansing agent(s) to air dry?

Letting a cleansing agent air-dry completely (30 seconds for chlorhexidine, 60 seconds for alcohol, 2 to 3 minutes for povidone-iodine) allows time for the agent to reduce microbial counts adequately.

What instructions should I give a patient who is being sent home with fecal occult blood test (FOBT) cards?

Make sure your patient has three FOBT cards. Tell him to collect samples from three separate bowel movements that are not contaminated with urine. Tell him to use the small wooden stick in the test kit to collect fecal samples and place them in the two windows on the card. Once the samples are in place, he can close the window over the card and label each card with the date and time of collection. Remind him to put his name and date of birth on the cards and to return them within 3 to 14 days of obtaining the sample. Suggest that he avoid red meats, poultry, fish, and certain raw fruits and vegetables, including radishes, turnips, and melons, for 3 days prior to testing and during the testing period, as these can lead to false-positive results, and to increase his water and fiber intake for a few days prior to testing. The patient should also avoid NSAIDs or discontinue NSAIDs or warfarin for 1 week prior to testing per the health care provider's prescription. Remind him that the test is meant to look for occult blood, which means that even if he does not see blood in his stool, it might still have blood in it.

What do filter tubing lines and inline filters do?

Many drugs are filtered during the manufacturing process to remove particulates of a certain molecular size. Numerous recommendations exist for filtration after the manufacturing process, depending on the medication and on the agency's policy. Many agencies require filtering all reconstituted powders; many require filtering all medications for particular patient populations (such as open-heart surgical patients). Check the recommendations for using a filter for a specific medication in an IV medication guide or consult a pharmacist. Using a filter when it is not recommended might reduce the potency of the medication.

Why do patients absorb medications differently even when they are given by the same route?

Many factors determine how fully and how quickly an injected medication is absorbed. With subcutaneous injections, local blood flow to the tissues affects absorption. Exercise and heat or cold application influence blood flow. Circulatory shock and occlusive vascular disease also affect blood flow and are contraindications for subcutaneous injections. When giving insulin, the site you use affects the rate of absorption. Insulin given into the abdomen is the most quickly absorbed, then the arms, then the thighs, and finally the buttocks, where it has the slowest absorption rate. To minimize variation in absorption from day to day, give insulin in one area, rotating sites within that area. With intramuscular injections, both blood flow and the amount of muscle tissue affect absorption of the medication. Avoid giving intramuscular injections into atrophied, poorly developed muscles. As with subcutaneous injections, circulatory shock contraindicates intramuscular injections.

When is it unsafe to give patients oral medications?

The oral route, including the buccal and sublingual routes, is inappropriate when a patient has a condition that alters gastrointestinal function, such as nausea and vomiting, reduced motility (after general anesthesia, for example), bowel inflammation, or surgical resection of portions of the gastrointestional tract. It is unsafe to give medications orally to patients who have difficulty swallowing, such as those with neuromuscular disorders, esophageal strictures, or mouth lesions, and those who are unconscious, unable, or unwilling to swallow or hold medications under their tongue. The oral route is also contraindicated when patients have gastric suction in place, before surgery, and before certain diagnostic tests. Some providers allow patients who are NPO (receiving nothing by mouth) prior to surgery or a test to take some oral medications with sips of water. After surgery, if a patient is NPO, oral medications are usually withheld or given by an alternative route until intestinal function resumes. Occasionally a patient with nasogastric suction has specific medications ordered to be given through the nasogastric tube. Typically, nasogastric suction would be stopped for about 30 minutes after medication administration, allowing time for the medication to be absorbed.

What is the difference between the sublingual and the buccal routes of administration?

The sublingual route is specific for medications designed to be absorbed readily after placement under the patient's tongue. The patient must not chew or swallow a sublingual medication or drink anything until it is completely dissolved; otherwise, the medication will not have the desired effect. If the patient's mouth is dry, wet the mucous membranes under the tongue with approximately 1 mL of normal saline solution or water to promote absorption. The buccal route involves placing a solid medication inside the mouth against the mucous membrane of the cheek until the medication is dissolved. Just like the sublingual route, patients must not chew or swallow it or drink any liquids with it. A local effect is achieved via the buccal route but can be used to achieve a systemic effect when the dissolved medication is swallowed in the patient's saliva. If subsequent doses are to be administered, the patient should alternate cheeks to avoid mucosal irritation.

What is the difference between the terms general hand hygiene and surgical hand asepsis?

The term general hand hygiene refers to decontamination of the hands by handwashing with an antimicrobial or plain soap and water or using an antiseptic handrub. You can sanitize your hands with the handrub if there is no visible soil. The term surgical hand asepsis refers to the antiseptic surgical hand scrub or antiseptic handrub performed prior to donning sterile surgical attire.

Should I take any special precautions when administering heparin?

There is a risk of bruising and pain with the administration of subcutaneous heparin, particularly low molecular weight heparin. To minimize these effects, do not remove the air bubble prior to injection. Administer the injection in the side of the abdomen. Inject the medication slowly, over 30 seconds. Wait for 10 seconds after injection before withdrawing the needle, then apply gentle pressure for 30 to 60 seconds. Do not massage the site.

What should I do if the needle hits a bone while I am administering an injection?

Withdraw the needle about ¼ inch but do not remove it. Proceed with administering the injection.

Is there a difference in the incidence of UTI in male and female patients?

Women are at higher risk for UTI because, compared with men, they have a shorter urethra and a shorter distance from the urethra to the anus. A shorter urethra increases the risk of infection because the distance for bacteria to travel into the bladder is shorter. Also, a shorter distance between the urethra and the anus increases the risk of fecal material and bacteria being introduced into the urethra. Men produce an antibacterial substance within their prostatic secretions, which also helps reduce the risk of infection. Advanced age (older than 60 years), prolonged indwelling catheter use, and lack of antibiotic prophylaxis increase the risk of UTI.

Define the term high-alert medications as it relates to medication errors.

Medications that have the highest risk of injuring patients when misused are termed high-alert medications. The Institute for Safe Medication Practices (ISMP) has two lists of high-alert medications. The first list is for community and ambulatory settings and contains such medications as oral anti-retrovirals, opioids, insulin, and oral hypoglycemic agents. The second high-alert list is for institutional healthcare settings and contains a variety of medications given by the intravenous route.

My alert and oriented patient's blood glucose reading was 435 after his afternoon snack. What should my next step be?

Monitor the patient continuously. Check agency protocol for laboratory confirmation testing of very high readings, as laboratory testing is considered more accurate. Attain the patient's medical record for a medication prescription related to increased glucose. Administer insulin or a carbohydrate source per provider prescription and notify the health care provider of the patient's response.

Why take a deep breath and completely exhale before inhaling aerosolized medication?

Instruct patients to take a deep breath and exhale completely prior to closing their mouth around the end of the inhaler to empty the lungs and prepare the airway for receiving the medication. This is an essential part of the process of using a metered-dose inhaler.

What are the advantages of using the topical route for medication administration?

Topical (skin) application of medications primarily provides a local effect. Avoid applying topical agents to skin abrasions (unless treating the abrasion, for example, with an antibiotic ointment) because these areas are at a risk for rapid medication absorption and systemic effects.

What extra precautions can I take to avoid wrong-route errors when giving an injection?

Besides diligence in checking the first five rights of medication administration at least three times to prevent medication errors in general, be sure to assess the injection site for adequacy of tissue, identify the landmarks for proper placement of the needle, and choose the appropriate needle length. These precautions will keep you from administering an injection in the wrong tissue type.

Why do some patients have a spacer attached to their metered-dose inhaler?

A spacer, such as an Aerochamber, is an optional component that fits into the end of a metered-dose inhaler (MDI). This device breaks up and slows down the medication particles released from the inhaler, trapping the medication in the chamber of the spacer and thus allowing the patient to inhale the medication from the chamber, increasing the amount of medication that goes into the patient's lungs. This process allows larger droplets emitted from the aerosol spray to be retained in the chamber while the smaller, finer particles of medication are inhaled, thus improving the drug's absorption into the patient's airway. A spacer is especially useful for patients who have difficulty inhaling slowly and deeply and for those who have difficulty pressing the inhaler's canister while simultaneously inhaling the medication.

Why should I use a time tape?

A time tape provides an easy reference for indicating the accuracy of the flow rate. You can adjust the flow rate of a gravity-flow infusion if the time tape shows that the fluid is infusing too quickly or slowly. Use time tapes with electronic infusion devices as well. These devices can malfunction and deliver fluids inaccurately; a time tape will help you detect a discrepancy quickly.

My 4-year-old patient is afraid of needles. How can I reduce her anxiety while also obtaining an adequate blood sample for her prescribed tests?

Apply a topical anesthetic cream as directed to the area you select for the venipuncture. Use the smallest size needle available for collecting the required amount of blood. Butterfly needles are quite small; you can use them to access the smaller veins in the hands, for example. Some facilities have pediatric child-life specialists who can provide life-size dolls to use when explaining medical procedures. These specialists can show the child what will be done and allow her to play with some of the equipment (modified, of course, for safety) to ease her anxiety.

What should I do if a patient pulls out a urinary catheter?

Assess the patient for changes in mental status and mechanical injury to the genitalia and check vital signs. If you see no evidence of significant injury, it is reasonable to re-insert the catheter. Notify the provider of the event.

How long can the influenza virus survive outside a host?

At room temperature, with moderate humidity, these viruses can live 24 to 48 hours on steel and plastic, and 8 to 12 hours on cloth and facial tissues.

What is autonomic dysreflexia and what should I do if I suspect that a patient has this condition?

Autonomic dysreflexia is a syndrome affecting patients with spinal cord injuries above the thoracic level. A stimulus from the autonomic nervous system causes hypertension, bradycardia, severe headaches, pallor below the level of injury and flushing above the level of injury, convulsions, stroke, and death. The most common causes are constipation and full bladders (which can be caused by clamping urinary catheters). The primary treatment for this condition is removal of the stimulus (or unclamping a catheter). Some medications are also prescribed to stabilize patients who have severe cases of autonomic dysreflexia.

Why should I backprime secondary tubing instead of just priming it?

Backpriming the secondary tubing fills the tubing backward, from the connecting end to the drip chamber. This ensures that none of the medication in the secondary bag is wasted or lost while you prime the tubing.

How should I alter my technique when I give ear drops to a child?

Because the external ear structures of children 3 years old and younger differ from those of adults, straighten the ear canal of infants and young children when instilling drops or irrigating solutions. Straighten the cartilaginous canal by grasping the auricle (pinna) of the ear and pulling it gently down and backward. The ear canal is longer in adults and is composed of underlying bone. For older children and adults, straighten the auditory canal by pulling the auricle upward and outward. Failure to straighten the ear canal might keep the medications from reaching the deeper external-ear structures.

How can I help prevent aspiration when I give oral medications?

Before giving oral medications, determine the patient's ability to swallow, the presence of a gag reflex, and the ability to cough. Prepare oral medications in the form that is easiest for the patient to swallow, administer one medication at a time, and make sure the patient swallows each medication. Thicken fluids if the patient has difficulty swallowing thin liquids, and place medications in the stronger side of the mouth if the patient has unilateral weakness. Assisting the patient to a lateral or an upright standing or sitting position or elevating the head of the bed protects the patient from aspiration while facilitating swallowing. Offering liquids helps ensure that the medication moves into the stomach and does not become lodged in the esophagus. For 30 minutes after administering oral medications, keep the head of the patient's bed elevated and the patient upright to help prevent aspiration. When the risk of aspiration is severe, ask the provider to consider prescribing another route of administration.

Should I change the tubing no more often than 96 hours for all fluid infusions?

Not necessarily. It is best to change any fluid that enhances microbial growth more often. For example, the CDC recommends changing infusion tubing on lipid emulsions and total parenteral nutrition every 24 hours. Check your agency's tubing-change policy for specific fluids, especially for blood products, parenteral nutrition, and lipids.

How can I give two IV piggyback medications scheduled for the same time?

Check your agency's policy for dose administration-time guidelines. Many policies allow infusion within 30 minutes before and after the scheduled time. Depending on the infusion's duration, it might be possible to infuse the medications sequentially. Start the first medication 30 minutes prior to the due time, flush the line between infusions with sterile normal saline to avoid drug incompatibility issues, then begin infusing the second medication within 30 minutes after the scheduled time.

What are the indications for urinary catheterization?

Common indications include an inability to void because of retention, risk of skin breakdown from severe urinary incontinence, the need for close hemodynamic monitoring, and post surgical recovery.

Why can't I use alcohol at the site when I discontinue an IV infusion?

Not only will the alcohol sting when it enters the open wound, it will also cause vasodilation and increase post-removal bleeding.

What should I do if I see blood in the syringe when I aspirate before administering an IM injection?

Do NOT administer the medication. Withdraw the needle, discard the needle and the syringe in a puncture-proof container, and prepare a new injection. If you administer the medication after seeing blood in the syringe, the injection would be considered intravenous and you would have given it via the wrong route.

Why do some medications require filtering prior to administration?

Drugs distributed in glass vials must be filtered on withdrawal from the vial to eliminate the possibility of drawing glass particles into the syringe. One process uses a standard needle to withdraw from the ampule and a filter needle to inject into the diluent bag. Another method uses a filter needle to withdraw the drug and a standard needle to administer it. Filter straws and other blunt filter devices are available for needleless systems.

Can I use the same the same secondary tubing for more than one medication?

Establishing a secondary line creates a means for micro-organisms to enter the primary line. Repeated changes of secondary tubing increase the risk of contamination. To reduce this risk, "backflush" secondary tubing whenever possible and use it for the length of time your agency allows. Many infusion pumps have a backflush or "back-prime" setting that allows the primary fluid to flow upward through the secondary tubing into the piggyback bag. You can also backflush by opening the secondary clamp and lowering the piggyback bag below the level of the primary IV bag. Each of these methods flushes primary solution through the secondary tubing, clearing the tubing of medication and air. Keep in mind, though, that some medications are incompatible and require separate secondary tubing. Check your agency's policy for backflush protocols.

Why must ear drops be sterile?

Even though the structures of the outer ear are not sterile, instilling nonsterile solutions into the middle-ear structures (for example, if the eardrum ruptures) could result in infection.

Is there a difference in the incidence of urinary tract infection (UTI) among the different types of catheters?

Indwelling urinary catheters have an increased incidence of UTI because of the prolonged time that they are in place. All catheters should be discontinued as soon as possible to reduce the incidence of adverse events.

How should I position a patient after instilling vaginal medication?

Instill vaginal medication with the patient in the dorsal recumbent position. This position provides easy access and good exposure of the vaginal canal, thus allowing for the vaginal medication to dissolve (if a suppository) and spread (cream, jelly, or foam) along the vaginal walls. Instruct the patient to maintain this position, if possible, for at least 10 minutes to keep the medication inside the vaginal canal and allow optimal distribution and absorption.

What is the average risk for a blood born pathogen/virus transmission after a needlestick injury?

Hepatitis B (HBV), 22% to 62%; hepatitis C (HCV), 1.8% to 7%; human immunodeficiency virus (HIV), 0.3% to 0.5%

My patient performed a home pregnancy test after missing a menstrual period. She said the test was negative, but a subsequent blood test confirmed that she is pregnant. How should I explain the discrepancy?

Home pregnancy tests are commonly misread, either because the test has expired, it was done too soon after a missed period so the hormone levels were not high enough to show a positive finding, or the sample was collected incorrectly. Many women read the test too soon or wait too long to read the test and end up with false results. Most home pregnancy tests have a very specific window of time between collecting the sample and reading the test. Also, some tests are more sensitive than others to the hormone that indicates pregnancy. For all these reasons, following up with a medical provider to confirm the results is always recommended.

How can I apply the Joint Commission's "two-identifier" rule safely in various patient care scenarios?

Identifying situations where a "wrong patient" scenario might occur is crucial. This error is possible not only in multiple-patient rooms but during any phase of medication administration and use. -A nurse might bring the wrong medication administration record (MAR) to the bedside to identify the patient. The risk increases for patients who have the same first or last name or similar hospital identification numbers. -A pharmacist could misinterpret an order due to poor visibility of the patient's name and identification number on a paper copy with an ink imprint or due to look-alike patient names. -A provider could prescribe medication for the wrong patient based on laboratory and other diagnostic data that belong to another patient. For example, incorrect labeling of patient monitors at the nurses' station can result in information reported for and treatment administered to the wrong patient. Measures that help prevent "wrong patient" errors include: -Bringing the MAR to the bedside for the identification of two unique patient identifiers -Using discretely separate work areas for each patient to prevent the mix-up of MARs, flowsheets, medications, specimens, and equipment -Replacing ink imprints on paper with laser-printed identification labels to improve clarity -Labeling cardiac monitors with multiple patients' rhythms using a standardized verification process involving two individuals ensuring accurate patient identification and treatment -Using bar codes and scanners to administer medications

Can I reuse a vaginal applicator for subsequent vaginal medication administration?

If indicated, you may wash the vaginal applicator with warm soapy water, rinse it, and store it for future use for the same patient.

How long can fingernails be?

Nails should extend no more than ¼ inch past the nail bed. Special care should be taken to clean the underside thoroughly. Artificial nails should be avoided.

Is it acceptable to wear artificial nails and fingernail polish in the surgical suite?

No. Artificial nails harbor organisms and prevent effective hand asepsis. In addition, fungi can grow under artificial nails as a result of the moisture trapped between the natural and the artificial nail. Nail polish that is chipped or worn longer than 4 days is associated with bacterial proliferation and infection.

Can I add medication to an existing bag or container of infusing IV fluid?

No. Because there is no reliable way to determine the volume of fluid left in the bag, you would not be able to determine the exact concentration of the medication in the solution. Add medications only to new IV fluid containers.

Can all sold forms of ora medication be crushed or chewed?

No. Enteric-coated tablets are covered with a hard surface that delays absorption until the tablet leaves the stomach and enters the small intestines. This form of tablet should never be chewed or crushed because the coating is designed to protect the patient's stomach from the irritating effects of the active ingredient, thus delaying absorption until it enters the small intestines. Other forms of oral medications that should not be chewed or crushed include those that are released over an extended period of time, such as sustained-release (SR), extended-release (XL), controlled-release (CR or CRT), and sustained-action (SA) preparations. MS Contin, for example, is a potent controlled-release opioid analgesic that would release a potentially toxic dose of morphine when a patient chews it or ingests a crushed or broken tablet. Always check with a pharmacist before crushing or allowing a patient to chew any medication.

Should I warm ear drops and irrigating fluid?

No. Instill ear drops and irrigating fluids at room temperature. The internal ear structures are very sensitive to temperature extremes; instilling drops or irrigating fluids at any temperature other than room temperature might trigger vertigo (disequilibrium), dizziness, or nausea. During the procedure, instill the ear drops on the side of the auditory canal to allow a gradual flow into the ear canal and a gradual adjustment to body temperature.

Are prescription eyeglasses or contact lenses an acceptable form of eye protection?

No. Neither eyeglasses nor contact lenses provide enough coverage to prevent infectious disease (splashes) via ocular exposure and transmission.

Can I write the drug information directly on the IV bag?

No. Never use a felt-tip marker or pen to write on the IV bag. The ink can penetrate the plastic and seep into the IV solution. Always use a facility-approved label to write the date, time, drug, dose, and infusion rate of the IV medication and/or solution plus any other information per your agency's policy.

When without a handkerchief or tissue, is it appropriate to "sneeze into your sleeve"?

Oddly enough, yes, this reduces the transmission of airborne infection.

When is it unsafe to give patients rectal suppositories?

Rectal suppositories are contraindicated for patients who have had rectal surgery or have active rectal bleeding.

What is the acceptable standard for removing a mask?

Remove the mask carefully by the ties, taking care to avoid touching the filter portion of the mask, and then discard it immediately. Handling the filter portion of the mask after use can transfer bacteria from the nasopharyngeal airway to your hands and initiate cross-contamination.

Is it necessary to remove excess air from the area where I intend to insert the catheter?

Removing the hair by clipping it allows the antiseptic cleanser(s) to clean the site optimally, improves visualization of the vein, helps the dressing and tape adhere to the skin, and reduces discomfort when the dressing and catheter are removed. Shaving is not recommended as it creates microabrasions that predispose the skin to infection.

Why should I rotate injection sites when giving serial or regularly scheduled injections?

Rotating injection sites prevents induration, abscess formation, and lipohypertrophy or lipoatrophy from repeated injections in the same tissue.

My patient is having difficulty generating a sputum sample for analysis. How can I help her produce a sample?

Teaching the patient to deep breathe and cough may help loosen and mobilize her secretions. Chest physiotherapy is also recommended as an intervention that may help loosen secretions deep in the chest. Try to obtain sputum samples early in the morning before the patient eats or drinks anything. If she tires from attempting to produce a sample, let her rest and return in a short time to ask her to try again. If the patient has a pain-control issue with coughing, pre-medicate her for pain as prescribed at least 20 minutes before asking her to cough and deep breathe to produce a sample. Be sure the client is coughing up sputum and not spitting saliva from clearing their throat.

How long can IV solutions be used?

The CDC offers the following guidelines for the length of time parenteral fluids may hang: -Hang lipid-containing solutions for no longer than 24 hours. -Hang lipid-only emulsions for no longer than 12 hours.-Hang blood and blood products for no longer than 4 hours. Although the CDC does not provide specific guidelines for other parenteral infusions, most institutions have infection-control policies in place stating that these fluids should not hang for longer than 24 hours at room temperature. Of course, if you suspect that an infusion is contaminated, you should stop it immediately and save it for testing.

What impact has the failure to identify patients correctly had on the healthcare industry?

The Joint Commission has cited patient misidentification as the root cause of many errors - medication errors, transfusion errors, testing and wrong procedure errors, and the discharge of infants to the wrong families. Missing armbands and inaccurate information also contribute to errors and limit the efficiency of a standardized patient identification process. The Joint Commission identified and introduced improving patient identification accuracy as the first of its National Patient Safety Goals, and it continues to be an accreditation requirement.

Can I use antecubital sites for IV insertion?

The antecubital site is not a good choice for an IV site. First, the antecubital space is an area of flexion, which increases the risk for kinks or dislodgement of the catheter. Immobilizing this joint to avoid these complications limits your patient's range of motion and might interfere with activities of daily living. Also, damage to this site eliminates the possibility of using many of the veins in the distal hand and forearm for IV therapy. Finally, you can access the antecubital vein repeatedly for blood sampling, so it is best to reserve this site for that purpose.

What are the best ways to get the air bubbles out of an infusion set?

The best way to control bubbles in IV tubing is to prevent them in the first place. There are several measures you can take to keep air from entering and to remove bubbles from an infusion set. Close the roller clamp on the tubing before spiking the IV bag. Hang the IV bag from an IV pole before priming the tubing. Fill the drip chamber by squeezing it until it is one third to one half full before priming the tubing. Use the roller clamp to control the flow at a rate that allows you to invert the injection ports before the fluid reaches them and to tap them as the fluid fills them. Use the roller clamp to control the flow at a rate that minimizes turbulence, which can create bubbles, and at a rate that allows you to check for bubbles and to tap and invert the tubing to remove any air you see.

How can I help prevent needlestick injuries?

The key is to develop good habits when using needles. Whenever possible, use needles equipped with safety devices. Grasp the cap at the base to snap it back over the needle. Slide the safety sheath over the needle immediately after use. Always use the one-handed scoop technique for recapping clean needles. Before administering an injection, always check for a usable sharps container within arm's length and at eye level. NEVER recap a contaminated needle. Always dispose of contaminated needles immediately. Never force a needle into a sharps container; you should be able to drop it into the container. Never carry contaminated needles around, and never dispose of them in a wastebasket.

What causes hematuria (blood in the urine)?

The most common causes of hematuria are mechanical injury of the urethra, urinary calculi (stones), genitourinary cancers, UTI, pyelonephritis (infection of the kidney), and glomerulonephritis (infection of the glomerulus structure in the kidney).

Would replacing the tubing more often help maintain the sterility of the IV infusion system?

To reduce the incidence of IV catheter-related infections, the Centers for Disease Control and Prevention (CDC) recommends that infusion tubing, including "add-on" devices, be replaced no more frequently than at 96-hour intervals but at least every 7 days. Add-on devices include extension tubing, secondary tubing, and infusion-port adaptors. Always discard and replace tubing or add-ons if you suspect contamination. Check your agency's policy, as it might differ.

How can I make an injection less painful for the patient?

To minimize the patient's discomfort when you administer injections, try these interventions: - If time allows, apply EMLA (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) cream to the injection site for 1 to 3 hours prior to the injection per provider prescription. Otherwise, try vapocoolant spray (an aerosolized volatile refrigerant liquid) or manual pressure just before giving the injection. - Administer medications that are at room temperature, not cold, when possible. Allow the skin-cleansing antimicrobial agent to dry before administering the injection. - If you used the needle to draw up the medication, replace it with a fresh, sterile needle before giving the IM injection so that any medication coating the needle will not irritate the tissues surrounding the muscle. - Use the smallest-gauge needle possible. - Position your patient in a flexed position and encourage him to relax his muscle. - Distract your patient during the injection. - Minimize movement of the needle by darting it in quickly, stabilizing the syringe while you are injecting the medication, and removing the needle quickly. - Apply gentle pressure at the injection site using a dry gauze pad or a cotton ball, not a wipe wet with a potentially irritating antimicrobial agent.

How can I prevent infection when administering an IM injection?

To prevent infection, perform hand hygiene. If the injection site is visibly soiled, wash the site with soap and water before cleansing it with an antimicrobial wipe. Maintain strict surgical aseptic technique during medication preparation and administration. Check the expiration date of all medications. Use a single-dose vial only once. Label a multidose vial with the date and time when it is initially opened, and refrigerate it if indicated on the label; discard it by the expiration date or according to your agency's policy. Keep the medication, the needle, the inside of the syringe barrel, and the plunger of the syringe sterile throughout the procedure.

How can I avoid injuring the patient when I administer an IM injection?

To prevent tissue irritation, tissue damage, and nerve damage, check for adequate tissue at the injection site and place the needle properly. Rotate injection sites if giving regular injections. Choose the appropriate length and size of needle. Never give irritating medications subcutaneously; inject them only into a large muscle. The ventrogluteal muscle is the best choice for irritating or oily medications for patients of any age. Do not give too large a volume of medication for the size of the muscle; do not inject more than 3 mL into a large muscle in an adult and 2 mL into an older adult or thin patient; do not inject more than 1 mL into a subcutaneous site. Give medications by the intramuscular route only when no other route is acceptable or available. Use the Z-track technique for all intramuscular injections to keep the medication from leaking out of the muscle into surrounding tissues. Do not massage the site after injection.

Under what conditions can I use alcohol-based handrubs?

Use alcohol-based handrubs to degerm your hands only if they are not visibly soiled. Alcohol-based handrubs are not appropriate for use when your hands are visibly dirty or soiled with proteinaceous materials (blood, for example), because these handrubs do not remove soil or debris.

Explain the Joint Commission's National Patient Safety Goals for hospitals in 2013 that focus on the accuracy of patient identification.

Use at least two ways to identify patients, such as using the patient's name and date of birth, before starting any treatment, drawing a blood sample, or giving a medication. Ensure that the correct patient gets the correct blood when giving a blood transfusion.

What is the best way to give a medication incompatible with an enteral feeding but ordered via the enteral tube?

Verify all medications for compatibility with the patient's enteral feeding before giving the medication. If the medication is incompatible, stop the enteral feedings 30 minutes, or per facility policy, before giving the medication and resume the feedings 30 minutes, or per facility policy, after giving the medication.

When must I wear protective eyewear in the surgical suite?

Wear protective eyewear - masks and goggles, glasses with solid side shields, or chin-length face shields - whenever you anticipate eye, nose, or mouth contamination as a result of spraying or splashing of blood droplets or other infectious materials.

If I wear scrubs into the facility from outside, do I need to change them before I enter the restricted and semirestricted areas of the surgical environment?

Yes. Scrubs, a form of surgical attire, help contain bacterial shedding and promote environmental control. You must replace them with a fresh pair to minimize the potential for contamination from uncontrolled environments. (Animal hair from home and different laundering techniques are examples of potential sources of contamination.)

Does a person who is bald have to don a surgical hat before entering the surgical environment?

Yes. The cap or hood is designed to minimize the microbial dispersal that occurs not only from hair but from the skin's bacterial shedding. That is why everyone entering the surgical environment must don head wear.

Does urinary catheterization always require a provider's order?

Yes. Urinary catheterization is a procedure that always requires a provider's order.

Do I have to remove my jewelry before I enter the surgical environment?

Yes. You must remove rings from your hands because they might harbor organisms that you cannot remove with handwashing. Higher bacteria counts have been noted when rings are worn. Generally, watches, earrings, bracelets, necklaces, piercings, and other jewelry are restricted. Although there is no verification that these jewelry items increase bacterial shedding, they can fall into a sterile field or into a surgical wound site. Necklaces have the potential of contaminating the neck of the sterile gown if not properly confined. Always consider the standards of care that apply to surgical attire as well as your institution's policies about wearing of jewelry in semirestricted and restricted areas of the surgical suite.