ADN Midterm
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| What gauge is a blue cannula? | show 🗑
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| show | 18
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| show | 20
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| show | vomiting, diarrhea, gastric suctioning, intestinal fistulas, intestinal drainage, diuretic therapy, renal disorders, endocrine disorders, sweating from excessive exercise, increased environmental temperature, hemorrhage, chronic abuse of laxatives
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| What is insensible water loss? | show 🗑
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| show | self limiting of fluids (fear of incontinence), physical disabilities, cognitive impairments, older adults without air conditioning
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| show | Greater than 10.2 mg/dl
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| What are some S&S of hypercalcemia? | show 🗑
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| What kinds of vital sign changes can you see in a patient with hypercalcemia? | show 🗑
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| What is the lab value for hyperkalemia? | show 🗑
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| What are the S&S of hyperkalemia? | show 🗑
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| What was the food Kristi told us to remember was high in potassium? | show 🗑
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| What are good sources of magnesium? | show 🗑
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| What is the average amount of water that can be lost in urine per day? | show 🗑
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| What are the 5 proper steps for a blood transfusion? | show 🗑
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| What do you do if your patient has a fever when you take the innitial set of vital signs prior to blood transfusion? | show 🗑
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| What should the RN verify that the MD obtained prior to transfusion? | show 🗑
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| What fluid do you use to prime the line and start the iv prior to blood transfusion? | show 🗑
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| show | 20 gauge or larger (the smaller the number, the larger the gauge)
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| show | YES
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| show | client's information, type of transfusion, name, birthday, MR#, unit#(identical on bag and requisition), blood type and rh factor, expiration date
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| show | yes and no. Delayed reactions can occur days to months after a transfusion which can be manifested by increased temperature, decreased hematocrit and mild jaundice
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| show | hypersensitivity, febrile, hemolytic, bacterial
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| show | fever, uticaria (hives), anaphylactic shock
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| What are the signs of a febrile transfusion reaction? | show 🗑
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| show | caused by blood incompatibility: nausea, vomiting, lower back pain, tachycardia, hypotension, hematuria, decreased urine output
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| What are the signs of a bacterial transfusion reaction? | show 🗑
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| What is anaphylactic shock? | show 🗑
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| show | Have they ever had a blood transfusion before. Greater risk of complication with each transfusion. (I think Kristi said problems after 10)
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| show | circulatory overload
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| What are assessment findings for fluid overload? | show 🗑
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| show | decrease flow rate, elevate HOB, watch for dysrhythmias, notify dr, O2, morphine sulfate for vasodilating
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| show | benadryl (airway management, O2, treat shock)
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| What medication might be given for a febrile transfusion reaction? | show 🗑
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| show | benadryl (airway management, O2, supportive care)
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| show | ATB, fluid recuscitation, vasopressors, corticosteroids (blood will need to be cultured)
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| What steps should you take when your patient has a transfusion reaction? | show 🗑
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| What do you need to consider before administering antibiotic IV piggyback? | show 🗑
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| show | verify med, prepare med, spike IVPB with secondary tubing, connect secondary tubing to port on primary tubing,ensure the connection is above the pump house,if fluid is running-no need for saline flush,if not flush with 2-3 ml of saline, set pump and start
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| show | monitor the infusion and document
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| show | STOP THE INFUSION. Treatment will be specific to the type of complication
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| show | leakage of a vesicant into surrounding tissue, stop the transfusion and call dr and pharmacy to determine appropriate protocol
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| What is infiltration? | show 🗑
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| What are the s & s of hematoma? | show 🗑
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| What steps can you take you take to prevent hematoma? | show 🗑
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| show | apply direct, light pressure with sterile gauze pad over site for 2-3 min, elevate extremeity over pt's head or on a pillow to maximize venous return, ice may be applied to prevent enlargement
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| How can you prevent thrombosis? | show 🗑
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| show | never flush to remove the clot, discontinue and restart in a different site, notify dr and assess site for circulatory impairment
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| What are S & S of phlebitis? | show 🗑
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| show | use large veins, central lines or picc's for long term or hypertonic solutions, use smallest cannula possible for solution, rotate site Q72-96 hrs, stabilize catheter, use good handwashing and IV techniques, change solution containers Q 24 hours
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| What is the phlebitis scale 0-4? | show 🗑
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| Does the risk of phlebitis increase after the first 24 hours? | show 🗑
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| When should peripheral iv's be changed? | show 🗑
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| What solutions pose a greater risk for phlebitis? | show 🗑
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| show | discontinue the infusion, apply warm or cold compresses, consult with physician
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| show | yes and no, could take days or weeks to develop
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| show | muscles nerves and vessels are all in compartments confined in flexible spaces bound by skin, fascia and bone.
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| What is compartment syndrome? | show 🗑
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| What is a rating of 0 the infiltration scale (0-4)? | show 🗑
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| show | 1. skin blanched,edema < 1in., cool to touch, with or w/out pain
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| What is a rating of 2 the infiltration scale (0-4)? | show 🗑
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| What is a rating of 3 the infiltration scale (0-4)? | show 🗑
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| What is a rating of 4 the infiltration scale (0-4)? | show 🗑
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| How can you prevent infiltration? | show 🗑
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| How do you treat infiltration? | show 🗑
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| What are the S & S of extravasation? | show 🗑
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| How do you treat extravasation? | show 🗑
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| What can cause local infections r/t iv therapy? | show 🗑
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| show | call dr, remove the cannula, culture tip and site and do blood cultures, apply sterile dressing, ATB as ordered, monitor the site
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| What is Best Practice when handling and discontinuing and IV? | show 🗑
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| What is the most accurate way to infuse? | show 🗑
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| What is the normal range for sodium? | show 🗑
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| show | 3.5 - 5-5
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| show | 1.5 - 2.5
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| show | 8.5 - 10.2
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| What is the normal range for phosphate? | show 🗑
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| show | NO
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| (Patient teaching) Does a patient need a medic-alert bracelet if they have an implanted device for long term use? | show 🗑
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| (Patient teaching) Are there any activity restrictions for patients with a PICC or CVAC? | show 🗑
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| (Patient teaching) Can a patient with a PICC and non-implanted CVAD bathe or swim? | show 🗑
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| show | yes - when it is not being accessed
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| How should you care for a central line insertion site? | show 🗑
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| How do you change a central line dressing? | show 🗑
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| show | prepare client, open and prepare infusion set, spike solution container, hang solution on pole, partially fill drip chanber, prime tubing, label container and tubing, apply timing label to container
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| What supplies do you need to discontinue IV? | show 🗑
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| show | gather supplies, explain procedure, wash hands, turn off iv, apply gloves, loosen dressing wile keeping catheter stabilized, apply gauze over site, remove catheter, press down, hold 2 min, inspect cath tip, document, check in 15 minutes
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| How long do you apply pressure after d/c an iv in a patient taking blood thinners? | show 🗑
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| show | catheters and needles (angio), infusion pump, regulatory devices, tubing, filters (clean gloves, adhesive tape or securement device, iv pole, tubing, syringe and med if giving iv med via push)
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| What are the special considerations when starting an IV on pediatric patients? | show 🗑
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| show | inspect for redness, swelling, tenderness, drainage, compare length of external portion of catheter with documented length to assess for displacement
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| show | yes, if they become soiled or not forming a seal around site. Use clean gloves, clean site with chlorhexidine, apply tegaderm
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| What are the special considerations for starting an IV on an elderly client? | show 🗑
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| Are they elderly at a greater risk of fluid overload and/or fluid deficit? | show 🗑
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| Can you use a BP cuff as a tournequet in older adults with delicate skin? | show 🗑
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| show | 1. Neo-adjuvant 2. Adjuvant 3. Palliative
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| When is Neo-adjuvant chemotherapy used? | show 🗑
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| show | AFTER surgery to make sure that any cancerous cells are killed
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| When is palliative chemotherapy used? | show 🗑
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| show | feet and scalp
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| show | men (adipose tissue does not have water content and women have more adipose tissue) 50-55% adult women and 55-60% adult men
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| show | 45-55% (less than adults therefore greater risk for fluid volume deficits) (elderly women at greatest risk!)
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| How much body water do infants have? | show 🗑
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| Who is the environmental theorist who pioneered concepts of light, cleanliness, ventilation, warmth, diet and noise? | show 🗑
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| Which theorist is known for fundamental NEEDS and The Nature of Nursing? | show 🗑
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| Which nursing theorist is known for the science of CARING? | show 🗑
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| show | Patricia Benner
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| show | Ida Jean Orlando
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| show | Madeline Leninger
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| Which nursing theorist is the Theory of Health as Expanding Consciousness Theorist? | show 🗑
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| Which nursing theorist proposed the Behavioral Systems Model? | show 🗑
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| Which nursing theorist proposed the thoery of Goal Attainment? | show 🗑
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| Which nursing theorist proposed the three levels of prevention (primary, secondary, tertiary)? | show 🗑
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| show | Orem
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| Which nursing theorist proposed the Adaptation model? | show 🗑
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| show | Peplau
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| show | Prevention, to protect oneself against environmental risks. Immunizations, sun screen, nutritious foods.
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| What is secondary prevention? | show 🗑
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| What is tertiary prevention? | show 🗑
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| show | Maslow
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| What are Maslow's hierarchy of needs? | show 🗑
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| show | positive Chvostek's or Trousseau's sign, tetany, laryngeal stridor, dysphagia, tingling around the mouth or extremities, increased GI motility and cramping, anxiety, irritability, decreased HR and hypotension, EKG changes
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| show | sudden, involuntary contraction of a vein or an artery resulting in temporary cessation of bloof flow through a vessel. R/T cold infusates, irritating solution, too rapid administration of IV solution or viscous solution.
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| show | it must be verified by x-ray
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| show | make sure Dr order was written prior to TPN bag change, keep TPN in refridgerater until 30-60 minutes prior to admin. the bag tubing and filter must be changed every 24 hours, check bag against the dr's order, inspect bag to ensure no fat globules present
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| show | yes
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| Can you start TPN at the physician's prescribed rate? | show 🗑
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| show | 24 hours
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| What do you need to monitor once TPN has been started? | show 🗑
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| Can you ever catch up TPN if it has fallen behind? | show 🗑
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| How do you D/C TPN? | show 🗑
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| Can the catheter used for TPN be left in 72-96 hours? | show 🗑
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| Can you give a piggyback into a line used for TPN? | show 🗑
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| show | Therapeutic communication
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| What does SOLAR mean? | show 🗑
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| Some other points to remember for therapeutic communication: | show 🗑
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| When is parenteral nutrition used? | show 🗑
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| Do dextrose and lactated ringers provide nutrition? | show 🗑
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| show | if a person has INCREASED nutritional needs due to trauma, burns, surgery or malnutrition
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| What does TPN contain? | show 🗑
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| show | NO. Must be administered through a central line whose tip lies in the superior vena cava.
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| show | 72 hours
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| How often do you need to change tubing for PN containing lipids? | show 🗑
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| Is infection a complication of TPN? | show 🗑
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| show | Hang D10 solution right away to prevent hypoglycemia
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| What kinds of metabolic problems can occur with TPN? | show 🗑
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| show | dislodgement, thrombosis of great vein, and phlebitis
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| show | 2-4 hours
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| show | draw a single line through the erroneous entry and write the time, date and your name/innitials. Make the correction in a way that preserves the original entry.
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| Does TPN require a filter? | show 🗑
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| show | a closed tip catheter aka Gershong
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| What is the name of the open tipped catheter primarily used for pediatric patients? | show 🗑
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| What do you call the adult sized open tipped catheter which opens directly into the bloodstream? | show 🗑
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| On a closed tip/Gershong catheter, why is there a valve at the tip? | show 🗑
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| show | decreased risk of air emboli or bleeding, no need for heparin flush, no need to clamp catheter, reduce flushing protocols between use.
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| What are some best practices to use when hanging an IV bag? | show 🗑
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| What should you teach the patient when innitiating IV therapy? | show 🗑
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| What is maintenence therapy? | show 🗑
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| What is replacement therapy? | show 🗑
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| show | therapy for concurrent or continuing losses
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| show | Iron overload (it is a delayed reaction)
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| show | nausea, vomiting, hypotension, elevated iron levels
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| show | with Desferal. Urine will look red during excretion of the iron. Monitor iron levels.
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| How often do you take vital signs when administering a blood transfusion? | show 🗑
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| Should you place the blood administration sheet in the appropriate place on the chart? | show 🗑
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| Should you change the blood set every 4 hours or with each unit of blood? | show 🗑
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