Mosby Tracheostomy Care

A nurse is teaching a new graduate nurse about tracheostomy tubes. Which statement by the new graduate nurse indicates understanding of the capabilities of a fenestrated tracheostomy tube?

"A fenestrated tube allows the patient to speak." A fenestrated tracheostomy tube allows speech when a fenestrated inner cannula is in place and the cuff has been deflated. Many patients with tracheostomy tubes of any sort have the ability to protect their airway enough to eat and drink normally. A fenestrated tracheostomy tube does not affect the production of mucus in the airway and thus does not change the necessary suctioning frequency for a patient.

Which statement indicates that the patient understands how to use the oxygen mask?

"I am allowed to take my mask off to eat." Rationale: The patient should remove the mask only to eat, blow the nose, expectorate, or vomit; a nasal cannula may be necessary to maintain oxygenation while eating. There should not be any flammable materials such as cigarettes around supplemental oxygen. The patient should be instructed to let the nurse know if the bag collapses because there will be decreased oxygen delivery if the bag is not inflated.

Blow-by oxygen therapy is initiated on a 2-year-old patient who is noncooperative with other traditional methods of oxygen delivery. This is facilitated by attaching oxygen tubing to an oxygen delivery source set to 10 L/min and held close to the child's face. What is the likely FIO2 that the child is receiving via this method?

0.4 Rationale: Because this use of blow-by oxygen therapy does not allow contact between the oxygen delivery device and the patient's airway, much of the oxygen escapes into the atmosphere and does not benefit the patient. When the oxygen delivery source is set to 10 L/min during blow-by therapy, the maximum FIO2 the patient is likely to receive is 0.4. An FIO2 of 0.6, 0.8, and 1.0 is not possible using this method.

The nurse assessing a patient's muscle strength finds full ROM against gravity with full resistance. What grade would the nurse assign to this finding?

5 Rationale: Muscle strength is graded on a scale of 0 to 5, with 5 being full ROM against gravity and full resistance. A grade of 4 indicates full ROM against gravity with some resistance. A grade of 2 indicates full ROM and passive resistance. A grade of 1 indicates slight contractility and no movement.

During the evening assessment, the nurse notices that the IV dressing is wet because the IV tubing to the IV cannula has a loose connection. What should the nurse do immediately after tightening the IV tubing and cannula connection?

Change the IV dressing. Rationale: All peripheral IV dressings should be secured to the patient's skin and must be changed when they become wet, soiled, or loose. Peripheral IV cannulas and certain fluid infusions can be associated with local or systemic infections, phlebitis, and infiltration. Reinforcing the dressing with gauze or simply applying new tape would hold moisture in and aid bacterial growth. The longer the dressing stays wet, the greater the risk of maceration and infection; therefore, waiting to change it until after the medication finishes infusing is not appropriate.

A CVC exit site dressing is moist but it is not due to get changed for another 3 days. Which is the appropriate action?

Change the dressing immediately. Rationale: Change transparent dressings at least every 5 to 7 days and when the dressing is not intact, the dressing is loose or moist, drainage or blood is under the dressing, or further assessment is needed for a suspected infection or complication.

Which action should the nurse include when providing tracheostomy care?

Cleaning the inner cannula with normal saline solution. Normal saline solution loosens secretions from the inner cannula and should be used to clean the inner cannula. The nurse should clean the area around the stoma starting at the stoma and working outward in order to pull contaminants to the periphery. New ties need to be applied before removing the old ties to prevent dislodgment. Suctioning after the procedure may cause the patient to cough secretions into the tube; tubes are usually suctioned before the procedure. There is no outer cannula to clean, only an inner cannula.

A nurse is educating a patient with a new CVC. Which teaching point should the nurse emphasize?

Do not disrupt the dressing on the CVC. Rationale: The patient should be instructed not to disrupt the dressing on the CVC because this may lead to infection at the catheter exit site. The patient should not develop redden skin after the dressing change. The patient should be instructed to report pain at the exit site because this is abnormal and may indicate the development of phlebitis. The patient should not be instructed to close the clamp on the catheter because this can lead to clotting in the catheter.

How often should a gauze dressing be changed on a CVC exit site?

Every 2 days Rationale: Gauze dressings should be changed at least every 2 days. Transparent, semipermeable dressings should be replaced every 5 to 7 days.

How often should a gauze dressing be changed on a peripheral catheter site?

Every 2 days Rationale: Gauze dressings should be changed every 2 days. TSM dressings should be replaced at least every 5 to 7 days.

To perform a Romberg test, what action would the nurse take?

Have the patient stand with feet together and arms at sides, both with eyes open and eyes closed, and observe for swaying Rationale: The Romberg test, used to evaluate balance, is performed by having the patient stand with feet together, arms at sides, with eyes open and then with eyes closed, and observe for swaying. The nurse checks for scoliosis by observing postural alignment. The nurse observes gait as part of the musculoskeletal assessment. The nurse tests for Homan sign by supporting the leg while flexing the foot in dorsiflexion.

Which technique helps ensure placement of an NG tube into the esophagus and the stomach as opposed to the lung?

Have the patient use the chin-tuck position. Rationale: The chin-tuck position is used for patients at risk for aspiration with swallowing because it helps access the GI tract rather than the airway. Hyperextension of the neck is the position for opening the airway, so it would have the opposite of the intended effect. Looking at the ceiling would probably result in neck hyperextension. Swallowing water may be helpful in advancing the tube after it has reached the nasopharynx, but if the patient cannot swallow safely or is distracted while swallowing, it may lead to coughing and opening the airway with resultant airway intubation.

Which is a potential complication of oxygen therapy via nasal cannula for patients?

Mucosal dryness Rationale: Because most oxygen delivery systems do not routinely use humidification, patients on continuous oxygen are at risk of mucosal dryness. Aspiration, feelings of suffocation, and feeling hot are potential complications of oxygen mask use but are not usually associated with the use of a nasal cannula.

An older adult patient requires placement of nasal cannula tubing for oxygen administration. Which action by the nurse helps to provide safe care to this patient

Placing padding between the cannula and the skin Rationale: In many cases, older adult patients have fragile skin, so the nurse should pad the skin to prevent breakdown. Taping the cannula to the skin may cause breakdown. Oxygen delivered via a nasal cannula should not be turned higher than 6 L/min, and the oxygen should be regulated according to the practitioner's order. The patient should not be instructed to remove the tubing because removal may cause hypoxia. The patient should be instructed to report whether the tubing becomes irritating.

Which intervention is a comfort measure that can ease the discomfort of NG tube insertion?

Provide a focal point for the patient, such as something to hold and squeeze as desired. Rationale: Providing a focal point as a means of distraction can help the patient have a sense of control and hopefully some level of comfort during tube insertion. Suggesting the potential for vomiting or that tube insertion will be uncomfortable will probably increase the patient's anxiety. Informing the patient that there will be some discomfort in the nostril and back of the throat is appropriate, but the nurse should also indicate that every precaution will be taken to minimize the discomfort. Tipping the patient's head backward may facilitate inadvertent passage of the tube into the lung more readily. The nurse should position the patient for comfort, with his or her head positioned in a forward position rather than tipped backward.

Proper care of CVCs includes which nursing action?

Replacing the dressing when it is damp, loose, or soiled Rationale: To maintain a sterile, occlusive dressing, the nurse should replace the dressing when it becomes damp, loose, or soiled. The site should not be cleansed every shift if the dressing is intact. Routine changing of dressings should occur every 2 days for gauze dressings and every 5 to 7 days for transparent dressings. Antibacterial ointments are avoided because they can promote fungal infections and antimicrobial resistance.

When assessing an adult comatose patient, the nurse found a positive Babinski reflex. Which response did the patient exhibit?

The great toe dorsiflexed Rationale: A positive Babinski reflex indicates central nervous system dysfunction. If a Babinski reflex is present, the great toe dorsiflexes and is accompanied by fanning of the other toes. Plantar flexion is the movement of the toes flex downward toward the sole.

An older adult patient has a history of falling and comes in with bruises on her arms and legs. During orientation, a new nurse is reviewing the patient's history for lifestyle behaviors and risk factors for musculoskeletal complications. Which action indicates that further practice and study is needed?

The nurse does not ask her if she has recently fallen. Rationale: It is important to review the patient's history for lifestyle behaviors and risk factors for musculoskeletal injuries. This patient has a history of falling and came in with injuries suggesting she may have fallen. Asking her if she has anemia, uses caffeine and who she lives with maybe important, however, she came in with bruising and a history of falling at home.

After quickly applying a nonrebreather oxygen mask to a patient with difficulty breathing, the nurse observes the patient's condition declining. What is the potential cause of this decline?

The oxygen tubing has been connected to the wrong gas. Rationale: In haste, the nurse may have connected the oxygen tubing to the wrong gas line, and this could cause rapid patient deterioration. The nurse should always check to make sure that the tubing is connected to oxygen. A securely fitting oxygen mask, full inflation of the reservoir bag, and 300 psi in the oxygen tank are all favorable conditions for optimal therapy.

In a patient with a PICC, phlebitis should be suspected if which condition is present?

The patient's exit site has erythema with pain. Rationale: Signs of phlebitis, include pain, erythema, edema, streak formation, and a palpable venous cord. The catheter migrating 1 cm is not ideal, but that may not cause phlebitis. If the catheter flushes well with good blood return, it is unlikely there is a phlebitis.

A patient with an NG tube and suction begins to complain of nausea and then vomits. What is the most likely reason?

The suction is not functional. Rationale: Patients with a correctly placed and functioning NG tube and suction should not have emesis. Immediately check to verify that the NG tube is not displaced or clamped off and that the tube is attached to a functional suction device if a patient complains of nausea or vomits. Patients who continue to experience nausea or vomiting are not better. Effective suction, like antinausea medicine, will keep the stomach empty and prevent vomiting. The tip of the NG tube with all the suction holes should be located in the body of the stomach; when the tip of the tube is directed toward or located in the fundus it does not function correctly.

When suctioning a tracheostomy tube, what should the nurse do?

When suctioning a tracheostomy, the nurse's dominant hand remains sterile and maneuvers the suction catheter. The unsterile nondominant hand is used to connect the suction catheter to the connecting tubing. Suction should be applied while withdrawing the catheter and never during insertion. The suction catheter must remain sterile, so the function of the suction equipment is tested using sterile solution. The entire suction pass should not last longer than 10 to 15 seconds in order to prevent a decrease in oxygen saturation.

The nurse is providing the other nurses on the unit with an in-service regarding the new IV securement devices. Which rationale is the best explanation for the purpose of these devices?

A stabilization device holds the catheter in place to prevent dislodgment, minimize vein irritation and infection, and improve patient outcomes. Rationale: A stabilization device holds the catheter in place to prevent dislodgment, minimize vein irritation and infection, and improve patient outcomes. Even with the use of a stabilization device, a dressing is required to cover the site. The dressing still needs to be changed at regular intervals. The stabilization device doesn't prevent bleeding or oozing.

While receiving tracheostomy care, the patient's oxygen saturation drops to 87%. What action should be the nurse's next intervention?

Administering 100% oxygen to the patient. When the patient's oxygen saturation level drops during tracheostomy care, the nurse should administer 100% oxygen the patient to increase the oxygen saturation level. The practitioner does not need to be called as the first action, but may need to be notified if the saturation does not improve. High negative pressure may increase tracheal mucosal damage and should not be used. The tracheostomy tube may eventually need to be replaced, but this is not the first action.

A 53-year-old patient with a history of COPD presents to the emergency department in respiratory distress. The prehospital care providers have placed the patient on a 100% nonrebreather mask. When the patient arrives in the emergency department, which action should be taken?

Apply a Venturi mask and titrate the oxygen flow to maintain a normal SpO2 Rationale: Because the patient has COPD and may have chronic hypercapnia, maintaining an SpO2 that is normal for the patient is important. A Venturi mask allows more precise delivery of oxygen concentrations between 24% and 50%. Increasing the oxygen flow rate may result in hypoventilation and possibly hypoxia and apnea. A nasal cannula at 2 L/min may not provide sufficient oxygen for this patient. The patient needs oxygen therapy and should not take off the mask.

To assess a patient's CN V, what action would the nurse take?

Apply a light sensation with a cotton ball to symmetric areas of the face Rationale: CN V (trigeminal) is assessed by applying light sensation with a cotton ball to symmetric areas of the face. The nurse must check CN V by assessing if the sensations are symmetric; thus, the nurse must evaluate both sides of the face. CN VII (facial) is evaluated by having the patient frown, smile, puff out the cheeks, and raise the eyebrows. CN IX (glossopharyngeal) and CN X (vagus) are assessed by having the patient speak and swallow.

A patient with trauma from a high-speed motor vehicle crash has obvious leg fractures but is talking. The patient has an SpO2 of 91% and does not appear to have any difficulty breathing. What should the emergency nurse do when this patient arrives at the emergency department?

Apply oxygen via a nonrebreather mask. Rationale: The nurse should apply oxygen via a nonrebreather mask. In the initial phase of care for injured patients, oxygen is never contraindicated, and insufficient oxygen administration may lead to hypoxia. The victim of a high-speed motor vehicle crash may have a serious internal injury, and the initial trauma assessment includes the administration of high-flow oxygen to maintain adequate oxygenation. Intubation is not considered at this time because the patient is able to breathe independently. After full evaluation and ruling out other serious injury, the oxygen administration may be reduced to a nasal cannula delivery, but the initial intervention is oxygen via a nonrebreather mask.

A patient with a high oxygen requirement is not tolerating a mask. Which intervention is the most appropriate for this patient?

Applying a high-flow oxygen cannula system Rationale: If a patient has high-flow oxygen requirements and is not tolerating a mask, a high-flow oxygen cannula system with warming and humidification may be used. A regular nasal cannula cannot effectively deliver oxygen at a flow rate of 10 L/min. This patient requires only high-flow oxygen; placing an endotracheal tube or a tracheostomy tube is not necessary.

How should the nurse determine if the patient's NG tube has become displaced?

Assess the external length and compare it to the external length when the appropriate position was initially verified by x-ray. Rationale: If the external length of the tube has increased, the tube has probably been pulled back and the position should be reassessed; observing a number or a mark where the tube exits the naris will help alert the nurse to tube displacement. Air inserted into a tube that is displaced into the esophagus may echo into the stomach, making it seem as if the tube is appropriately positioned. Gastric pH may vary depending on what has been infused through the tube; although an acidic pH reflects increased likelihood of gastric fluid, an alkaline fluid return does not indicate that the tube is not in the stomach. A change in the color of gastric returns could raise suspicion about migration of the tube into the small intestine, but an x-ray would be needed to positively confirm this.

Which intervention is the most important for proper NG tube function?

Assessing the patient's symptoms and abdominal status, as well as returns via the tube Rationale: If properly functioning, an NG tube placed for decompression of the stomach should improve the patient's symptoms of nausea, vomiting, bloating, or feeling of fullness, and the amount and type of suctioned gastric contents would be unchanged from the initial insertion. A return of the patient's symptoms with a decrease in the amount of suctioned contents would indicate a nonfunctional NG or suction. Patients with NG suction are at risk for fluid and electrolyte abnormalities. An increase in serum sodium or a decrease in serum potassium, chloride, or urine output would indicate a need for IV fluid and electrolytes to replace the fluid lost from the NG suction. The presence or absence of stool has no relationship to NG function and more likely signals the return of bowel function or decreased bowel function, respectively.

The nurse is educating an older female adult about preventing bone demineralization. Which instruction would be included in the patient's education plan?

Begin a proper weight-bearing exercise program Rationale: To reduce bone demineralization, the nurse should instruct older adult patients to begin a proper weight-bearing exercise program that includes activity three or more times a week. Increased vitamin D aids in calcium absorption. Postmenopausal women who are not taking estrogen should consume increased doses of calcium daily.

Which nursing technique is appropriate when caring for a patient who has an NG tube in place for decompression after gastric surgery?

Elevate the head of the bed, unless contradicted by the patient's condition or practitioner's order. Rationale: Elevating the head of the bed helps prevent esophageal reflux. The NG tube of a patient who has undergone gastric surgery should not be repositioned because that could rupture the suture line. Fluid should not be introduced through the air vent lumen of the NG tube—this lumen is intended to provide a cushion to reduce the potential for tissue damage related to suction. The NG tube should be irrigated with sterile water as prescribed, not air or normal saline, to maintain tube patency.

The nurse suctions the tracheostomy tube of a patient who received a tracheostomy the night before. When suctioning, the nurse notices a moderate amount of bloody secretions. The patient notices the blood and appears to be disturbed by it. What should the nurse do next?

Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion. For patients with a new tracheostomy, the nurse should explain that bloody secretions may occur after initial placement of the tracheostomy tube and after each tracheostomy tube change. Turning the lights down so that the patient has difficulty seeing the secretions may only increase the patient's anxiety and stress. Because this is an expected finding, there is no need to notify the practitioner. More vigorous suctioning may lead to more bleeding.

During the IV dressing change, the nurse completes a thorough assessment of the IV site and notices slight redness and edema at the insertion site. What is the appropriate nursing intervention?

Discontinue the IV. Rationale: Redness indicates inflammation, and edema indicates infiltration with fluid infusing into the surrounding tissues. Neither a clean dressing nor warm compresses resolves the underlying problem. Even if there is blood return, signs of inflammation and edema require that the IV cannula be removed immediately.

The nurse is caring for a comatose patient in the ICU with multiple peripheral IVs. How often should the nurse assess the catheter insertion site for evidence of infection, infiltration, and phlebitis?

Every 1 to 2 hours Rationale: The catheter exit site should be assessed every 1 to 2 hours for patients who are critically ill and patients who are unable to verbalize pain or have sensory or cognitive impairment. The catheter exit site should be assessed every 4 hours for nonvesicant nonirritant infusions and for patients who have no sensory deficit due to medications or cognitive impairment. The site should be assessed at least every hour for children or neonates. Complications such as infection, phlebitis, and infiltration require removing the peripheral VAD and inserting a new one at a different site.

Preferred dressings vary with a patient's specific circumstances. What is the best dressing for a patient who is diaphoretic or a patient with a bleeding or oozing site?

Gauze and tape dressing Rationale: Gauze and tape dressings are the best choice for a patient who is diaphoretic or has bleeding or oozing from the site. They help to absorb some of the moisture, while maintaining their adhesive properties and staying occlusive. An adhesive bandage is nonocclusive; therefore, it is not a good choice as a dressing regardless of the circumstance. A TSM dressing is the preferred dressing for peripheral IVs; however, these dressings do not retain adhesive properties when wet. Elastic bandages do not allow visibility of the sight to assess for signs of phlebitis or infiltration, and they may compromise the patient's safety.

Which assessment tool is used to measure a patient's LOC?

Glasgow Coma Scale Rationale: The Glasgow Coma Scale is used to assess a patient's LOC. The Snellen chart is used to assess the patient's distance vision and the Rosenbaum chart is used to assess the patient's near vision. The six cardinal positions of gaze exam is used to assess extraocular eye movement.

What should the nurse do before removing a patient's NG tube?

Insert a small bolus of air into the lumen to clear fluid from the tube. Rationale: Inserting a small bolus of air into the lumen of the NG tube clears gastric fluids from the tube, preventing aspiration of contents or soiling of clothing and bedding. The nurse should explain the procedure to the patient, reassuring him or her that removal is less distressing than insertion because the tube will come out smoothly. Rather than exhale, the patient should take and hold a breath because temporary airway obstruction occurs during tube removal. Facial tissues can be offered to the patient as a comfort measure for blowing the nose immediately after tube removal.

The nurse is changing a dressing over the patient's IV catheter insertion site. When removing the tape and dressing, what should the nurse do?

Keep one gloved finger on the catheter until it is secured. Rationale: Keeping one gloved finger on the catheter prevents it from becoming dislodged. Adhesive bandages are not used to secure IV catheters because they are not occlusive. The antiseptic solution should be dry to be effective. Patients may or may not be able to follow instructions for not moving their arm while a new dressing is prepared.

A patient has redness, drainage, and pain at the CVC exit site as well as a fever. Which nursing intervention is the most appropriate?

Notify the practitioner and discuss further interventions to confirm CLABSI. Rationale: The nurse should notify the practitioner and discuss interventions to confirm CLABSI before catheter removal because catheter salvage is the goal. The practitioner may order a culture of the site. IV fluids can be continued until the practitioner determines if a new CVC will be inserted or a peripheral line can be used. Cleansing the catheter with antiseptic solution or applying povidone-iodine ointment does not treat a central line infection.

When assessing a patient's LOC, the nurse observes that the previously alert patient will not identify his name or location. What would the nurse do next?

Notify the practitioner immediately Rationale: A fully conscious patient is oriented to name, time, and place. As consciousness diminishes, the patient may show an unwillingness to cooperate. The practitioner should be notified immediately of this change. The deterioration in LOC should not be disregarded for any period of time because the patient may deteriorate further in that time. Documenting unwillingness to cooperate does not result in interventions to treat the underlying problem.

When securing the tracheostomy ties, the nurse should tie the ends in a double square knot, allowing for which outcome?

One loose or two snug finger widths of slack The nurse ties the ends securely in a double square knot, allowing space for only one loose or two snug finger widths in the tie. One finger width of slack prevents ties from being too tight when the tracheostomy dressing is in place and also prevents movement of the tracheostomy tube into the lower airway. Two loose or three snug finger widths is too loose and can lead to dislodgment of the tube. Securing the ties too tightly can cause excessive pressure on the tissue and cause skin breakdown along with interrupting blood flow because it can place pressure on vessels in the neck. No slack in the ties can lead to tissue compression and breakdown in the trachea or other internal structures and to areas of irritation around the insertion site.

A patient's elbow has full ROM but the patient does not have the strength to move it. Which type of ROM is this?

Passive ROM Rationale: Passive motion is when the joint has full ROM, but the patient does not have the strength to move it independently. Active motion is when the patient needs no support or assistance and is able to move joint independently. Active assisted ROM is when the patient uses the muscles surrounding the joint to perform the exercise but requires some help with a piece of equipment such as a strap. Full ROM the joint has full movement potential.

Which action should the nurse take when changing a CVC dressing on a diaphoretic patient?

Place an occlusive gauze dressing over the catheter exit site. Rationale: An occlusive gauze dressing should be placed over the catheter site. Transparent dressings do not stay in place on diaphoretic patients. They become loose, and a sterile, occlusive dressing is not maintained. Antibacterial ointments are avoided because they can promote fungal infections and antimicrobial resistance.

What should be done if resistance is encountered when initially attempting to insert an NG tube?

Pull the tube back slightly and angle it downward. Rationale: If resistance is encountered, the nurse should pull the tube back slightly and gently angle it downward to advance it around the nasopharynx. The tube should not be forced past resistance because this causes trauma to the mucosa. If there is still resistance after applying gentle downward pressure, the nurse should withdraw the tube, allow the patient to rest, relubricate the tube, and insert it into the other naris. The nurse should stop the procedure and notify the practitioner if unable to insert the tube into either naris.

The nurse sets the oxygen flow rate too low for use with a nonrebreather mask. What risk does this pose to the patient?

Rebreathing carbon dioxide Rationale: Setting the flow rate too low may collapse the reservoir bag and cause the patient to rebreathe carbon dioxide. Setting the flow rate too low does not cause pressure injuries. If carbon dioxide is allowed to accumulate, the patient is at risk for hypo-oxygenation, not hyperoxygenation. Because of the decreased oxygen intake, there is no risk in this case for oxygen-induced hypoventilation.

When removing the old dressing from a patient's CVC site, the nurse should include which step?

Remove the catheter stabilization device. Rationale: The catheter stabilization device should be changed with the dressing change. There is no need to place a dry cotton towel under the patient's arm as the catheter is not in the patient's arm. Nonsterile gloves are used to remove the old dressing; after the old dressing is removed, sterile gloves should be donned to place a new dressing. The old dressing should be lifted off beginning at the catheter hub and gently pulled toward the exit site; this prevents catheter dislodgment in the event the catheter sticks to the dressing.

When assessing a 12-year-old patient, the nurse notices asymmetry of the shoulder and hips. The patient has no complaints of pain. The nurse realizes that this finding may be indicative of what problem?

Scoliosis Rationale: Scoliosis, lateral curvature of the spine, is often revealed by asymmetry of the shoulders and hips. Lordosis is evidenced by an increased lumbar curvature. Kyphosis presents as an exaggerated posterior curvature of the thoracic spin. A patient with a slipped disk usually has numbness, tingling, and pain.

A patient with right ear trauma requires oxygen therapy with a nasal cannula. How should the nurse affix the tubing?

Secure the tubing to the patient's face with a transparent dressing. Rationale: If a trauma patient has an injury that interferes with normal placement of the nasal cannula tubing, the tubing can be secured to the patient's face with tape or a transparent dressing. Placing both loops of the tubing over the patient's left ear would not hold the tubing in place. Placing netting over the patient's head would be irritating to the patient and would not secure the cannula in the correct position. The patient cannot be expected to lie totally still, and this position would not promote healing.

The nurse is changing a peripheral IV dressing. The site is wet from diaphoresis so the nurse decides to use a gauze dressing instead of a TSM dressing. How should the nurse secure the gauze dressing?

Securely tape the entire surface of the dressing and all edges. Rationale: A gauze dressing should be secured by taping the entire surface and all the edges. An elastic bandage covers the site and prevents visual inspection. Leaving one edge untaped or leaving the surface uncovered allows for potential contamination of the site

The nurse is orienting a new graduate nurse and they are discussing how often to change peripheral IV dressings. Which response demonstrates the new graduate nurse's proper understanding of IV dressing changes?

TSM dressings should be changed every 5 to 7 days unless they become wet, or soiled, or is not intact." Rationale: TSM dressings should be changed every 5 to 7 days, or more frequently if they become wet or soiled, are no longer intact, or have blood or drainage under them. They may also be changed more frequently if there is any suspicion of infection or other complication. Gauze dressings should be changed every 2 to 3 days.

A patient with a right upper extremity CVC reports pain, swelling, and tenderness of the extremity. No fluids are infusing through the catheter. The nurse knows that these signs and symptoms may indicate which CVC-associated complication?

Thrombophlebitis Rationale: Signs of thrombophlebitis or venous thrombosis include pain, swelling, and tenderness caused by inflammation of the vein in conjunction with the formation of a thrombus. Catheter occlusion is the inability to flush the catheter or withdraw blood and has no visible signs. Infiltration or extravasation is an inadvertent leaking of fluids into the tissue; however, this patient has no fluids infusing. Initial symptoms of a CLABSI would include fever.

Which procedure should be used to cleanse the catheter exit site of a patient who is allergic to chlorhexidine?

Use swabs to apply a povidone-iodine solution in a circular motion, moving outward from the exit site in concentric circles. Rationale: If chlorhexidine is contraindicated to cleanse the CVC site, use tincture of iodine, an iodophor, or 70% alcohol. Chlorhexidine should not be used at all if it is contraindicated, not even if diluted. If an alcohol solution is used, it needs to be 70% alcohol. Normal saline alone will not adequately cleanse the site.

The nurse is changing the dressing of a peripheral IV. After removing the old dressing, which technique is the preferred method for preparing the site

Using a greater than 0.5% chlorhexidine in alcohol solution, scrub back and forth for at least 30 seconds. Rationale: Using a greater than 0.5% chlorhexidine in alcohol solution and scrubbing back and forth for at least 30 seconds is the preferred method for site preparation. Although povidone-iodine and 70% alcohol solution can be used if there are contraindications to chlorhexidine, greater than 0.5% chlorhexidine in alcohol solution is still the preferred solution. The site should be scrubbed back and forth vigorously for at least 30 seconds and then be allowed to dry completely. The site should be scrubbed back and forth and not in a circular motion. Scrubbing for 60 seconds is not necessary.

The nurse has just inserted an NG tube for medication administration. What is the best way to accurately verify its placement?

Verify through radiographic examination. Rationale: Radiographic verification is the gold standard for determining NG tube placement. Injecting air while listening for the air bolus does not pinpoint the location of an NG tube and is not recommended. Aspirating gastric content and checking pH may be helpful to assess placement, especially when used together, but radiographic verification is the best method.