NUA 361 Quiz 1

PICC line duration

6 mo

A+ transfusion options

A+ A- O+ O-

A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse?

"I will notify the physician that the current dose of medication is not relieving your pain."

Clients must contend with chronic illness daily. Nurses relate more effectively to clients when they understand the following as characteristics of chronic illness. Choose all that apply.

-The management of chronic conditions is a process of discovery. -Chronic illness affects the entire family. -Managing chronic conditions must be a collaborative process.

signs/causes of catheter occlusion

-bent catheter -catheter resting against catheter wall -knot or kink in IV tubing -blood clot formation

signs of hematoma

-bleeding under skin -bruised appearance

Symptoms of hemolytic reaction

-chills -headache -backache -dyspnea -cyanosis -chest pain -tachycardia -hypotension

clinical indication for 26 gauge catheter

-continuous or intermittent infusion in adult, peds, neonate, elderly -admin of blood products in adults, peds, neonates, elderly

clinical indication for 20 gauge catheter

-continuous or intermittent infusions -blood transfusion in adult pt

clinical indication for 22 gauge catheter

-continuous or intermittent infusions in adult, elderly or children -admin of blood products in adults, peds, neonate, elderly

intervention for catheter occlusion

-determine cause -consider removal -reposition to improve flow -DO NOT FLUSH (could cause embolus if clot is dislodged)

tourniquet placement

4-6 inches (10-15 cm) above insertion site

intervention for IV infiltration

-stop infusion -remove IV -elevate effected extremity -avoid applying pressure as it could make it worse or damage tissue

Implanted infusion port

-surgically placed under the skin -must be accessed with Huber needle

clinical indication for 14, 16, 18 gauge catheter

-trauma -surgery -rapid blood transfusion -rapid fluid replacement

Central line devices and placement

-tunneled -nontunneled -placed by physician (usually surgical)

Modified blood products (meant to reduce risk for pt)

-washed blood -irradiated blood -leukocyte-reduced blood

Blood products

-whole blood -RBC -platelets -plasma -cryoprecipitate

Common isotonic solutions

-D5W -NS -0.9% NaCl -0.9% NS -LR

A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse?

"It will enable the patient to remain home if that is what is desired."

A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give?

"Tell me more about what's on your mind"

Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care?

"Tell me who or what gives you strength."

A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse?

"When your stay reaches 6 months, you will be recertified for a continued stay."

Common hypotonic solution

- 1/2 NS - 0.45% NS - 1/3 NS

AB+ transfusion options

AB+ AB- A+ A- B+ B- O+ O- ***universal recipient***

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason?

Allows for the nurse to facilitate the grieving process

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross?

Anger

B- transfusion options

B- O-

O+ transfusion options

O+ O-

Which statement is a misconception about chronic disease?

Chronic illnesses cannot be prevented.

Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services?

Clients and families view palliative care as giving up

O- transfusion options

O- ***universal donor***

A nurse prepares a diabetes prevention health seminar for community residents. Her teaching points should emphasize the most important factor influencing metabolic syndrome (pre-diabetes). What is that factor?

Obesity

A client has had multiple admissions for heart failure. The client is now on continuous oxygen, bedridden, and provided care by his family. The nurse discusses end-of-life preferences with the client. The nurse assesses the client is in the phase of the Trajectory Model of Chronic Illness known as

Downward

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

Durable power of attorney for health care

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following?

Explore own feelings on mortality and death and dying.

The Joint Commission is Nonprofit

False

Which of the following is an appropriate method of assessing the dying client?

Focus on the client's basic needs

A patient who is at risk for developing a chronic condition because of genetic factors is said to be in which phase of the Trajectory Model?

Pretrajectory

A nurse is assessing a client with a terminal illness and finds that the client has cachexia. The nurse interprets this as indicating which of the following?

Profound protein loss

A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth?

Provide gentle oral care after each meal.

Which is one level of hospice care covered under Medicare and Medicaid hospice benefits, includes a 5-day inpatient stay, and is provided occasionally to relive the family caregivers?

Respite care

A terminally ill client is receiving morphine around-the-clock for pain control. As part of the client's plan of care focusing on pain management, which nursing diagnosis would the nurse most likely identify?

Risk for constipation related to the effects of an opioid

The nurse is with a client who has a chronic illness and is reinforcing positive behaviors and teaching about health promotion. For which phase of the trajectory model of chronic illness are these nursing actions appropriate?

Stable

Which of the following describes the crisis phase of the trajectory model of chronic illness?

The client is experiencing a critical or life-threatening situation requiring emergency treatment

A diabetes nurse is performing health education with a 44-year-old woman who has recently learned that she has type 2 diabetes. The nurse is teaching the patient the importance of adhering to her prescribed treatment regimen. When providing this health education, the nurse should emphasize:

The fact that adherence to a prescribed treatment regimen usually requires careful planning

Hypotonic fluid administration risk

exacerbate hypotensive state

Isotonic fluid administration risk

fluid overload in pt with renal or cardiac disease

Tx for extravasation

hyaluronic acid

Hypertonic fluid administration risk

irritating to the vein and can cause increased risk for heart failure or pulmonary edema

Autologous transfusion (autotransfusion)

method in which patient's own blood is collected and re-infused for the purpose of intravascular volume replacement

degree and bevel placement for IV start

puncture skin at 10-30' angle with bevel up

Hypertonic solution is used to

reduce cellular fluid (fluid shifts from the cell to the blood vessel)

Hypotonic solution is used to

replace cellular fluid (fluid shifts from the blood vessel to the cell)

Central line duration

several mo (depending on type)

Implanted port duration

several years (if cared for properly)

Hemolytic reaction

systemic response to the administration of a blood product that is incompatible with that of the recipient

Health promotion

the process of enabling people to increase control over their health and it's determinants

intervention for cath related infections

-notify provider -obtain order for culture -remove IV

Complications of central lines

-occlusion -infection (systemic and local at insertion site) -phlebitis -infiltration or extravasation -air embolism -thrombosis formation -catheter migration -catheter damage

clinical indication for butterfly needle

-one time infusion IV push -venipuncture for phlebotomy

signs of phlebitis (vein inflammation)

-pain -redness -warmth -swelling -induration (venous sclerosis) -palpable cord along vein

signs of infiltration

-pain -swelling -cool to touch -presence of blanching

signs of nerve injury

-pt complains of paresthesias -shockline pain -tingling (pins and needles) -numbness on insertion

signs of catheter-related infection

-redness -swelling around or above site -pain -purulent drainage at site -body temp elevations

interventions for hematoma

-remove catheter -immediately apply pressure -apply dry sterile dressing -monitor for additional bleeding or dysfunction -elevate extremity

Common hypertonic solution

-D10W -D50W - 3% NS - 5% NaCl - D5 0.9% NaCl - D5 0.9% NS - D5 NS - D5 0.45% NaCl - D5 0.45% NS - D5 1/2 NS - D5 LR

Advantages for central lines

-decreased risk for irritation and clot -avoid inflammation and scarring from recurrent needle sticks -decrease pt anxiety -reduce chances of infiltration by utilization of larger vein -can be used long term

PICC line insertion

-inserted into large vein, tip threaded through, rests in right atrium -placed by trained nurse or radiologist

IV site selection

-most distal site -non-dominant hand -avoid areas with pain upon palpation -avoid side of breast or lymph node surgery -avoid affected side in stroke pt -avoid areas of flexion (wrist, antecub) -avoid ventral wrist due to pain

B+ transfusion options

B+ B- O+ O-

Which statement provides accurate information related to chronic illness?

Most people with chronic conditions do not consider themselves sick or ill.

Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise?

Mutual Pretense Awareness

A type of comprehensive care for clients whose disease is not responsive to cure is

Palliative care

intervention for phlebitis

-notify provider -determine cause -if cause is chemical: apply heat, elevate limb, slow IV rate, possible removal -if cause is mechanical: apply heat, elevate limb, monitor for 24-48 hrs, remove if signs persist if cause is bacterial: remove IV

AB- transfusion options

A- B- O- AB-

A- transfusion options

A- O-

If a patient cannot afford a procedure, the hospital incurs the cost

True

Which of the following should the nurse report so that the team can consider alternative nutritional and fluid administration routes for a dying client?

Weight loss and inadequate food intake

intervention for nerve injury

-notify provider -immediately stop insertion -remove VAD -monitor neurovascular status

A client has lost mobility following a stroke. The nurse has established interventions that include providing direct care to the client, teaching, making referrals, and managing the case, to meet the goal. The next step is to

Plan with the client how to incorporate the regimen into the client's activities of daily living.