NUR 336 Exam 2
What is the best way to protect a patient from an IV site injury when giving an antibiotic medication by piggyback? A. Use a site into which a primary solution is already infusing. B. Assess the IV site before initiating the IV piggyback medication. C. Select a relatively small vein to infuse the IV medication. D. Instruct NAP to notify you immediately if the insertion site appears swollen.
B
Syringe size for ID
1 mL
Needle size for IM
1-1/2 inch (23-25 gauge)
Syringe size for SubQ
1-3 mL
Site choices for SubQ injection (3)
1. Abdomen 2. Thigh 3. Back of the arm
Needle size for SubQ
3/8-5/8 inch
What are the 6 assessments of the Braden Scale?
1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear
Site choices for IM injection (3)
1. Ventrogluteal 2. Vastus lateralis 3. Deltoid
Needle size for ID
25-27 gauge (3/8-5/8 inch)
When cutting the skin barrier wafer, how large should the circle be?
3-4 mm (1/8) larger than the stoma
What is the lowest score you can receive on a Braden Scale? Is that good or bad?
6. Bad.
What is the most important task to use when preventing the spread of infection? a. Performing hand hygiene.
A
When preparing to administer heparin or insulin subcutaneously, which site is preferred? A. Abdomen B. Scapula C. Deltoid muscle D. Back of the upper arm
A
Which action would the nurse take to minimize the patient's risk for infection when changing the dressing on a CVAD? A. Use sterile technique throughout the process. B. Apply a stabilization device if the initial sutures are no longer intact. C. Apply a mask to the patient during the procedure. D. Change the transparent dressing every 48 hours.
A
Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter C. Performing proper hand hygiene and applying gloves before inserting the catheter D. Terminating the insertion if the patient reports pain at any time during the procedure
A
Which of the following is an example of a parenteral route of medication administration? a. Intramuscular b. Topical ointment c. Suppository d. Enteric-coated capsule
A
When administering an IV piggyback medication to infuse by gravity, how can the nurse ensure that the medication will flow properly? A. Use an infusion pump to regulate the flow rate of the piggyback medication. B. Hang the piggyback medication higher than the primary fluid. C. Attach the piggyback medication to the most proximal insertion port on the primary tubing. D. Use a secondary infusion set for the piggyback tubing.
B
Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine."
A
What is the most important way in which the nurse can reduce the risk for infection in a patient with a CVAD that has a gauze dressing? A. Change the dressing every 48 hours. B. Apply sterile gloves to remove the original dressing. C. Cleanse the catheter and insertion site with sterile saline. D. Label the dressing with the date and time of application and the nurse's initials.
A (A gauze dressing on a CVAD should be changed every 48 hours and as needed. Doing so will reduce the patient's risk for infection. It is not necessary to wear sterile gloves to remove the soiled dressing. Cleansing the site with sterile saline will not minimize the patient's risk for infection. Labeling the dressing will not minimize the patient's risk for infection.)
A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing? a. Small amount of serous drainage b. Moderate amount of sanguineous drainage c. Small amount of serosanguineous drainage d. Small amount of purulent drainage
A (A small amount of serous drainage is normal postoperatively. A moderate amount of sanguineous drainage would indicate bleeding. Purulent drainage would indicate infection.)
When preparing an injection that contains both short- and intermediate-acting insulins, what is the first step the nurse would take to ensure the effectiveness of the injection? A. Insert air into the intermediate-acting insulin. B. Warm the vials to room temperature. C. Shake the vials to disperse the medication within the suspension. D. Withdraw the prescribed amount of short-acting insulin after the intermediate-acting insulin.
A (Air is injected into the intermediate-acting insulin before it is injected into the short-acting insulin. Warming the vials to room temperature will enhance patient comfort but will not ensure the effectiveness of the insulin injection. Shaking insulin is not recommended, as it may damage the protein molecules. Short-acting insulin must be drawn up before intermediate-acting insulin.)
What is the nurse's initial action when preparing to change a patient's colostomy pouching system? A. Applying clean gloves B. Draping the patient appropriately C. Emptying the colostomy D. Assessing the surrounding skin for signs of irritation.
A (Applying gloves first will protect the nurse while checking the stoma for leakage and assessing the patient's skin for irritation. Although it is appropriate to drape the patient, first put on gloves. The nurse will need to empty the pouch but this is not the best initial action. Although it is appropriate to assess the skin, doing so would not be the nurse's first action.)
When preparing an injection of mixed insulin that includes 12 units of NPH and 5 units of regular insulin, how does the nurse initially confirm the proper dosage in the syringe? A. By noting when 5 units of clear insulin is visible in the syringe B. By noting when 12 units of cloudy insulin is visible in the syringe C. By having another registered nurse verify the presence of 17 units of insulin D. By verifying that the prescription confirms the medication administration record (MAR)
A (Because it is clear, regular insulin will be drawn into the syringe first, so it is the first thing the nurse will verify as she draws the proper dosage. NPH or cloudy insulin is not drawn into the syringe first. While this confirms the correct total insulin volume, it fails to confirm the first step of drawing the clear, regular insulin. Although this confirms the amount of insulin prescribed, which is important, it does not address the amount of insulin in the syringe.)
What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? A. Examine each naris for patency and skin breakdown. B. Place the patient in the high-Fowler's position. C. Anesthetize the throat. D. Have the patient take a few sips of water.
A (Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort.)
Which of the following is a correct sequence for changing a gauze dressing? a. Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing. b. Remove old dressing, discard gloves, apply new gloves, and apply new dressing. c. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, and cover with thicker woven pad (e.g., ABD pad). d. Create sterile field, remove old dressing, discard gloves and perform hand hygiene, apply new gloves, clean wound, blot dry, apply new dressing.
A (The nurse should remove the old dressing, inspect the wound, dispose of gloves and soiled dressings, and perform hand hygiene. The nurse then creates a sterile field and applies new sterile gloves and cleans the wound from least contaminated (the surgical incision) to the most contaminated (the drain). The nurse dries the area in the same manner and puts on the new dressing.)
Which site is most commonly used for intramuscular injections? A. Ventrogluteal B. Abdominal C. Deltoid D. Dorsogluteal
A (The ventrogluteal site is the preferred IM injection site for adults and children, but not for infants and toddlers. The abdomen is used for subcutaneous injections. The deltoid site is an appropriate choice for small volumes, but it is not the preferred site for intramuscular injections. The dorsogluteal site is contraindicated for intramuscular injections.)
The doctor has just ordered a central line insertion on one of your clients. Which of the following tasks may be delegated to a NAP? (Select all that apply). a. Assist with positioning the patient during insertion and care. b. Reporting if the patient has a fever. c. Assessing the site for redness or irritation. d. Reporting to the nurse if the catheter line appears to have been pulled out further than its original insertion position. e. Inserting the central line using aseptic technique. f. Changing the central line dressing.
A B D (The NAP may assist with positioning the patient and making sure they are comfortable during the procedure. The NAP can also check for fever and if the catheter line as moved. They cannot insert the catheter or change the central line dressing or assess the site for infection.)
When mixing rapid or short acting insulins with intermediate acting insulins, you should: (Select all that apply). a. Roll the vial between your hands for suspension. b. Inject air into the longer-acting insulin first, without touching the medication to the needle. c. Draw up the short-acting insulin first. d. Verify that the correct dosage of insulin has been drawn up with a second nurse. e. Draw up the longer acting insulin first. f. Not push any insulin back into the longer acting insulin vial.
A B D E F
Which of the following are functions of dressings? (Select all that apply.) a. To promote hemostasis b. To keep the wound bed dry c. Wound debridement d. To prevent contamination e. To increase circulation
A C D (Dressings provide several functions, which include debridement, maintaining a moist wound environment, protecting from outside contamination and further injury, preventing the spread of microorganisms, increased patient comfort, and promoting hemostasis by control of bleeding. Dressings are unable to increase circulation.)
Which of the following patients would be expected to benefit from a moist-to-dry dressing? (Select all that apply.) a. A 24-year-old patient with an open and infected wound from a spider bite b. A 7-year-old with abrasions on the knees c. A 50-year-old with a postoperative knee-replacement incision d. A 30-year-old who had a large cyst removed and now has some necrotic tissue present in the crater-type wound
A D (Moist-to-dry dressings are best used with necrotic, infected wounds requiring debridement. Moist dressings are often used for helping to heal full-thickness wounds that look like craters. Dry woven gauze dressings are most often used for abrasions and postoperative incisions when minimal drainage is anticipated.)
What position should you put a patient in when performing ostomy care?
Semi-fowlers
What type of stool would you see with a descending colostomy?
Semiformed to formed
When administering an intradermal injection, which outcome would require the nurse to withdraw the needle and begin again? A. Aspiration of blood prior to injecting the medication B. Inability to feel resistance when injecting the medication C. Formation of a 6-mm bleb at the injection site D. Appearance of a lesion resembling a mosquito bite at the injection site
B
Which action by the nurse ensures patient safety when administering an intramuscular injection? A. Putting on clean gloves before administration B. Rotating injection sites C. Aspirating for blood return when administering a vaccine D. Injecting the medication quickly
B
Pale, red, watery: mixture of two types of drainage
Serosanguineous
Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? A. Massage the site after administration. B. Make sure the volume of the medication is less than 2 mL. C. Administer the injection at a 45- to 90-degree angle. D. Wear clean gloves while administering the injection.
B
The patient is to receive both Lantus® (insulin glargine) and regular insulin. To ensure the proper action of the insulins, what would the nurse do when preparing these two types of insulin for administration? A. Mix the insulins in one syringe for a single injection. B. Prepare the insulins in two syringes for separate injections. C. Roll each vial between the palms to disperse the medication within the suspension. D. Have another registered nurse verify the dose of the insulins.
B
Clear, watery plasma drainage
Serous
Before administering an IV medication piggyback, what should you check for with the IV?
Aspirate for blood return
How can the nurse minimize the risk of dislodging the catheter when removing a dressing? A. Lower the patient's head during the dressing change. B. Remove the transparent dressing or tape and gauze in the direction of catheter insertion. C. Apply skin protectant while the stabilization device is off. D. Cleanse the insertion site quickly and gently in concentric circles.
B
Which instruction reflects the nurse's correct understanding of the role of nursing assistive personnel (NAP) in caring for a patient receiving an intravenous (IV) antibiotic medication by piggyback? A. "Assess the IV site frequently for signs of infiltration." B. "Let me know immediately if the patient complains of pain at the IV site." C. "Notify the physician that the patient is allergic to the medication prescribed." D. "Remember to hang the piggyback medication higher than the primary solution."
B
Which of the following is an example of a nonparenteral route of medication administration? a. Intravenously b. Topical ointment c. Subcutaneously d. Intramuscular
B
During a sterile dressing change, when are the gloves changed? a. After the old dressing is removed and before creating a sterile field b. After the old dressing is removed and before cleansing the wound c. After the old dressing is removed, after cleansing the wound, and before applying a new dressing d. It is unnecessary to change gloves for chronic wounds.
B (Gloves are discarded after removing the old dressing. If required, a sterile field is then prepared, new sterile gloves are applied, and the wound is cleansed. It is unnecessary to change the gloves frequently unless they are accidentally contaminated. Gloves are changed after removing the old dressing and before cleaning the wound to reduce transmission of cross-contamination microorganisms. The same gloves may then be worn for applying a new dressing. Clean gloves may be worn rather than sterile gloves with chronic wounds (check facility policy).)
What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? A. Ask the patient to cough. B. Withdraw the tube to the nasopharynx. C. Encourage the patient to swallow. D. Instruct the patient to hyperextend the neck.
B (If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced. If the tube meets resistance, neither swallowing nor hyperextending the neck will help to advance it.)
A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? a. "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care facility." b. "Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around the wound, and that the skin is thoroughly dry before applying the dressing." c. "This type of dressing requires frequent changing because they do not stay in place." d. "You probably are applying it incorrectly, or perhaps you are just too anxious about having to perform the dressing change." e. "There are many options on the market. Why don't you try to use a non-adhesive-backed transparent dressing instead?"
B (If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches or 2.5 to 3.75 cm) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non-therapeutic.)
What is the best way to prevent infection and conserve resources when terminating an IV piggyback medication infusion in a patient who also has a primary fluid infusion? A. Remove the tubing from the primary line Y-site port, and cap the end. B. Leave both the piggyback tubing and the bag attached to the primary line Y-site port until the next scheduled dose. C. Place an unopened secondary setup at the bedside, and discard the used one. D. Change both the primary and secondary tubing upon terminating the piggyback infusion.
B (Leaving the piggyback tubing and bag attached will help maintain tube sterility while conserving supplies and nursing time. Although the tubing can be removed from the port and capped, it is better to leave the tubing and bag in place until the next scheduled dose. Secondary tubing can be reused for up to 72 hours. Changing the tubing with each piggyback infusion is expensive. It is unnecessary to change the primary and secondary tubing when terminating an infusion of IV piggyback medication.)
The nurse is preparing to mix short- and intermediate-acting insulins to administer to a patient. Which action best preserves the insulin's effectiveness? A. Determining the patient's blood glucose level B. Refraining from injecting the intermediate-acting insulin into the short-acting vial C. Applying clean gloves when administering the medication D. Having another registered nurse verify the dose of both types of insulins
B (Refraining from injecting the intermediate-acting insulin into the short-acting vial will prevent the short-acting insulin vial from being contaminated with intermediate-acting insulin. Determining the patient's blood glucose level will not ensure the effectiveness of the insulin. Wearing clean gloves will not ensure the effectiveness of the insulin. Having another nurse verify the dose will not ensure the effectiveness of the insulin.)
The nurse is observing the patient's wife perform the moist-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed? (Select all that apply.) a. Premedicates for pain b. Packs wound tightly c. Leaves contact or primary dressing dripping moist d. When removing the old dressing the wife leaves the dressing dry, even when it sticks slightly.
B C (Inner gauze should be moist to absorb drainage and adhere to debris. The wound should be loosely packed to facilitate wicking of drainage into the absorbent outer layer of the dressing. The wound should never be over packed because this can cause wound trauma when the dressing is removed. Premedicating for pain will help provide comfort during the dressing change. If dressing sticks on a moist-to-dry dressing, the wife should gently free the dressing and alert the patient of discomfort. The wife was correct in not wetting the dressing as a moist-to-dry dressing should debride the wound.)
When educating a client about using an incentive spirometer, you should make which of the following statements? (Select all that apply). a. Use the incentive spirometer once every 1-2 hours. b. Use the incentive spirometer 10 times every 1-2 hours. c. Sit upright when using your incentive spirometer. d. When using the device, exhale slowly until the piston rises to your goal. e. After you complete the session, cough and deep breathe a few times to clear the mucus from your lungs.
B C E
Non-blanchable erythema of intact skin. The skin may appear red and feel warm to touch.
Stage I pressure ulcer
Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center.
Stage II pressure ulcer
This scale measures pressure ulcer risk
Braden scale
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient.
C
During the procedure of inserting an NG tube, it is important that the patient: a. Holds their breath. b. Breathes through their nose. c. Breathes through their mouth and swallows consistently. d. Keeps any feelings of discomfort to themselves.
C
How can the nurse determine that the needle tip for an intradermal injection is in the dermis? A. A bleb the size of a mosquito bite will appear. B. The needle will enter at a 5- to 15-degree angle. C. The bulge of the needle tip will be visible through the skin. D. The needle will penetrate through the epidermis to a depth of about ⅛ inch.
C
One of your patients is receiving an IV medication by piggyback. Which of the following actions may NOT be delegated to an assistive personnel? a. Reporting any indication of possible side effects the patient may be having to the nurse. b. Reporting any changes in the patient's condition or vital signs. c. Administering IV medications by piggyback. d. Reporting patient discomfort at the IV site or moisture at the IV site.
C
The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? A. Begin to establish a sterile field. B. Open and assemble the urine drainage bag. C. Remove soiled gloves, and perform hand hygiene. D. Center the drape over the patient's labia.
C
When inserting an NG tube, the nurse should place the patient in which position: a. Semi-Fowlers b. Dorsal recumbent c. High-Fowlers d. Supine
C
When preparing an intramuscular injection, what can the nurse do to reduce the patient's risk for infection? A. Wear clean gloves. B. Use a 3-mL syringe. C. Clean the injection site with an alcohol swab. D. Massage the injection site.
C
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag.
C
Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? A. 20-gauge, ½-inch B. 22-gauge, 1-inch C. 25-gauge, ⅜-inch D. 27-gauge, 1-inch
C
Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient who is prescribed an intradermal injection? A. "Be sure to wear clean gloves during the injection." B. "Tell him it's OK; the site should look like a mosquito bite." C. "Immediately report any patient complaints of itching or dyspnea." D. "Remind the patient to come back in 48 to 72 hours so we can evaluate the site."
C
Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient with a dressed central venous access device (CVAD) site? A. "Assess the site frequently for signs of inflammation." B. "Be sure to change the transparent dressing on the site once every 7 days." C. "Let me know immediately if the patient's dressing becomes damp." D. "Make sure the patient knows to notify me if the site becomes painful or swollen."
C
What can the nurse do to minimize the discomfort of a subcutaneous injection? A. Inject the medication rapidly. B. Massage the injection site. C. Cover the injection site with gauze pad after withdrawing the needle. D. Inject the medication without pinching the skin.
C (Covering the nonintact skin of a subcutaneous injection site with a gauze pad, rather than with an alcohol swab, will reduce discomfort. Rapid injection of medication will increase discomfort. Massaging the injection site can cause discomfort and tissue damage. Injecting the medication without pinching the skin will not reduce discomfort.)
What can the nurse do to minimize the patient's risk for injury when delivering an intramuscular injection? A. Instruct the patient to relax. B. Insert the needle at a 45-degree angle. C. Pull back on the plunger after inserting the needle. D. Pull the skin taut at the injection site when inserting the needle.
C (Pulling back on the plunger will allow the nurse to determine if the needle is in a blood vessel, rather than in muscle tissue. Encouraging the patient to relax may decrease discomfort, but will not reduce the patient's risk for injury. For an intramuscular injection, the needle must be inserted at a 90-degree angle. Pulling the skin taut when inserting the needle will not reduce the patient's risk for injury.)
In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness
C (The deltoid area is not an acceptable intradermal injection site for any patient. If the forearm and back cannot be used, it is acceptable to use sites routinely used for subcutaneous injections. The upper back is an acceptable intradermal injection site for a patient on bed rest. The left forearm is an acceptable intradermal injection site.)
What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? A. Ask another nurse to attempt the insertion. B. Document the attempts in the patient's medical record. C. Notify the physician that the attempts were unsuccessful. D. Allow the patient to rest for 30 minutes before resuming the process.
C (The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient.)
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Deep crater with or without undermining of adjacent tissue.
Stage III pressure ulcer
Which action would the nurse take when mixing intermediate- and long-acting insulins together in one syringe? A. Draw the intermediate-acting insulin into the syringe first. B. Draw the long-acting insulin into the syringe first. C. Prepare two injections. D. Draw either the intermediate- or the long-acting insulin into the syringe first.
C (You never mix long-acting insulin with any other insulins. You would need to prepare two injections because you never mix long-acting insulin with any other insulins.)
What will the nurse do after removing the soiled dressing from a patient's CVAD device? A. Cleanse the site with soap and water. B. Use 2% chlorhexidine swabs to cleanse the site. C. Apply a skin protectant. D. Remove the catheter stabilization device, if present.
D
Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? A. Using a 1-inch needle B. Inserting the needle at a 45- to 60-degree angle C. Withdrawing the needle immediately after delivering the medication D. Aspirating for blood return before injecting the medication
D
Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? A. A raised wheal the size of a mosquito bite B. A bruised area 10 mm or greater in diameter C. A hard, raised area 15 mm or greater in diameter D. A flat, reddened area 5 mm or greater in diameter
D
Which nursing intervention is most important in ensuring safe infusion of a medication delivered by IV piggyback through a saline lock? A. Use the most proximal insertion port on the primary tubing. B. Hang the piggyback solution higher than the primary infusion solution. C. Use a pump to regulate the infusion rate of the piggyback medication. D. Flush the saline lock with sodium chloride solution before initiating the infusion.
D (Flushing the saline lock with 0.9% sodium chloride solution to assess for placement and patency before initiating a piggyback infusion reduces the likelihood of infiltration and extravasation. The piggyback is connected directly to the saline lock, not to primary tubing. There is no primary infusion solution when infusing piggyback medication directing through a saline lock. Although using an infusion pump to regulate the infusion rate of a piggyback medication may be appropriate, it is not the most important intervention for ensuring safe infusion.)
When pouching a patient's colostomy, which action reduces the patient's risk for injury? A. Measuring output when emptying the contents of the pouch B. Maintaining the patient's bowel elimination function C. Promoting the patient's autonomy with bowel elimination care D. Protecting the skin from irritation caused by fecal drainage
D (Protecting the skin from irritation caused by fecal drainage ensures correct pouching and prevents injury associated with skin breakdown. Measuring output when emptying the contents of the pouch does not reduce the risk for injury. Maintaining the patient's bowel elimination function does not reduce the patient's risk for injury. Promoting the patient's autonomy with bowel elimination care does not reduce the patient's risk for injury.)
What can the nurse do to ensure proper site selection for subcutaneous insulin injection? A. Insert the needle at a 30-degree angle. B. Select a different anatomical region for each injection. C. Ask the patient to relax before inserting the needle. D. Systematically rotate sites within the same anatomical location or area.
D (Systematic rotation within one anatomical location will allow consistent insulin absorption. The correct needle angle for a subcutaneous injection is 45 to 90 degrees. Administering the injection at a 30-degree angle will not deliver medication to the subcutaneous tissue. Furthermore, injection technique has no bearing on site selection. Changing anatomical regions for each insulin injection is not recommended. Asking the patient to relax will help decrease discomfort during the injection, but doing so will not ensure proper site selection.)
How often should you change the skin barrier/pouch for a colostomy?
Every 3-7 days
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. This is the most severe pressure ulcer formation and is most difficult to treat.
Stage IV pressure ulcer
Site for ID flu vaccine
Deltoid muscle
Before administering an IVPB, you should do what to check for infiltration of the IV?
Flush with 2-3 mL of NS
How full should the drip chamber be?
Halfway full
What do you document after administering an IVPB?
Immediately after administration, document in the MAR, the name and concentration of the medication delivered by IV piggyback, the volume infused, the start and stop time of administration, and the venous access device type and location.
Intrinsic factors contributing to pressure ulcer formation
Immobilization, cognitive deficit, chronic illness (diabetes mellitus), poor nutrition, aging
What type of stool would you see with a colostomy of the ascending colon?
Liquid stool
What type of stool would you see with a transverse colostomy?
Liquid to semiformed stool
Three closed drain systems
Jackson-Pratt, Hemovac, Wound-Vac
Site for allergy and TB tests (ID)
Palm side of forearm about 2 to 4 inches below the elbow
Which site is commonly assessed for skin breakdown when a patient has an NG tube inserted?
Naris and mucosa
You are assessing a patient's stoma. The stoma looks purple, black or grey. Are these colors normal?
No
Your patients stoma fails to bleed when washed gently. Is this normal?
No
What type of stool would you see with a sigmoid colostomy?
Normal
One open drain system
Penrose drain
4 extrinsic factors that contribute to pressure ulcer formation
Pressure, friction, humidity, shearing force
When healing occurs by _____ _____, the edges of the wound are pulled together and approximated with sutures, staples, or stripes of adhesive tape. Gradual formation of scar tissue allows the wound to close slowly
Primary intention
Thick, yellow, pale green, or white drainage: indicates infection
Purulent
Bright red: indicates active bleeding
Sangineous
What type of stool would you see with an ileostomy?
Thin or thick liquid, may be pasty
When should you empty an ostomy bag?
When it is more than 1/3 to 1/2 full
You are assessing a patient's stoma. It is moist and reddish pink. Some blood is present. Is this normal?
Yes
