Skills exam 5
Positive TB look like
15mm or more- no risk factors 10mm or more- immigrants, drug users, residents/ employees high risk facilities, chronically ill, children under 4yo 5mm or more- HIV +, fibrotic changes in X-ray, hx TB, immunosppressed
Sites for ID injections
Inner aspects of forearm Scapular area of back May use- outer aspects of arm or upper chest
indwelling catheter
remains inside the body for a prolonged time based on need
Amount of pressure for adult suction
100-150 mmHg
Ventrogluteal site
20-25g for aqueous 18-25g for viscous 1/2- 2inches length 1/2- 1 inch for children 1-3mL volume (max 5mL)
Needle length and gauge for sub-q MMR injection
21-25 g 1/2 inch
Needle size for subQ
23-25g
Needle size for ID
26-27g
Angle for SubQ
45-90
Angle for ID
5-15 degrees
How long after removal of catheter should pt void
6 to 8 hours
Amount of pressure for neonate suction
60- 100
Angle for IM injection
90 degrees
Which statement is correct regarding negative pressure wound therapy
A suction pump is used Chronic ulcers are reduced by removing fluids from the wound
Tips for subq
When using insulin or heparin continue to pinch skin while injecting Do not massage the site
What complication does air not in the tubing prevent
Air embolism
sites for subQ
Back of arms Thighs Stomach
Proper way to administer ampule
Breakaway from you Always use hand protection Use **filter needle** to draw up medications Always change needles prior to injection
Deltoid site
Children above 18 mo 20-25g for aqueous 18-25g for viscous Length 1/2 -1 inch Up to 2mL volume
Which action would the home health nurse take when caring for a client with pink& moist left leg venous stasis ulcer
Clean the wound with normal saline & apply prescribed hydrocolloid dressings weekly
A client has a large open abdominal wound. The HCP prescription states to clean with normal saline, pack it with damp gauze, cover with abdominal pads & secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing
Cleanse the wound with wet sterile guaze from the center of the wound outward
While caring for a client with a portable wound drainage system, the RN notices the collection container is half full. The RN empties the container. Which intervention should the RN do next?
Compress the container before closing the port
D5W
Dextrose 5% in water
Proper technique for z track method
Displace skin and subcutaneous layer tissue laterally for z teach method
What can be delegated to the UNP for a client with pressure ulcers
Empty wound drainage Report changes in wound appearance
What way should wounds be cleansed?
From the center outward or top to bottom
Hypertonic
Greatly expanded intravascular spaces Irritating too vein Increase risk of HF D5NS, D5LR, D10W
Which dressings would the nurse view as beneficial for the recovery of a clients red colored wound that was caused by pressure?
Hydrocolloid dressings Transparent film dressings Non adhering dressings from antibiotic ointment
a RN is evaluating the statements of a new nurse about wound dressings. Which statement is incorrect
I should use the cotton swab placed on the table
IVPB
Iv piggy back
Which interventions promote perfusion and healing of the surgical wound of an older adult
Keep the patient adequately hydrated
LR
Lactated ringers
What insulin's can not be mixed with other insulins
Lantus Levemir
Hypotonic
May cause sudden fluid shift from vessels into cells Can exacerbate hypotension 1/3 NS, 1/2 NS
What is normal in urostomies but not colostomies
Mucus
NS
Normal saline
The RN is about to perform wound irrigation on a client who had a left hemispheric stroke. What assessment is the most important prior to wound irrigation?
Pain
Which action would the RN take 1st after observing serosanguineous drainage on the abdominal dressing of a client in PACU who had an abdominal cholecystectomy?
Reinforce the dressing
The RN assesses the clients incision site after bariatric surgery for signs of dehiscence. Which clinical finding supports the RN's conclusion the client is experiencing a wound dehiscence?
Sharp increase of serosanguineous drainage
Where and what do newborns get injected
Vitamin K Vastus lateralis
A RN teaches a family member to cleanse a clients wound and apply sterile dressing. Which action by the family member indicates the need for further education?
Using back & forth motion with the same gauze while cleaning
How would the RN classify a wound that exhibits some soft necrotic tissue with a semiliquid slough & exudate
Yellow
straight catheter
a catheter that drains the bladder and then is removed
Coude catheter
curved and has a rounded or bulbous tip that is easier to insert into the male urethra when the prostate is enlarged.
Sites for IM injections
deltoid, ventrogluteal, vastus lateralis
D5LR
dextrose 5% in lactated Ringer's
D5NS
dextrose 5% in normal saline
PCA
patient controlled analgesia
TKO
to keep open (vein)
