Final Exam Fundamentals

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Questions and Answers

What position should a patient be placed in during a tracheostomy care procedure?

Supine position

Left side-lying position

Trendelenburg position

Semi-Fowler’s position (correct)

What is the purpose of rinsing the inner cannula with sterile saline after cleaning it?

To reinforce the sterility of the cannula (correct)

To reduce inflammation in the airways

To stop bleeding from the trachea

To prevent airway obstruction

What is the correct action when changing the ties of a tracheostomy tube?

Remove both sides of the tie simultaneously

Remove one side of the cotton tie at a time (correct)

Avoid stabilizing the tracheostomy tube

Tie the new ties before removing the old ones

Which of the following is a crucial step before suctioning a patient?

Assess the respiratory status Signup and view all the answers

What should be done with the irrigation solution during a sterile procedure?

Ensure it flows from least contaminated to most contaminated Signup and view all the answers

When performing a 24-hour urine collection, what should a patient do at the beginning of the collection period?

Discard the first urine output Signup and view all the answers

What should be done if a patient shows bladder distension after removal of an indwelling catheter?

Assess for bladder distention during the absence of output Signup and view all the answers

What should be done after administering an enema to the patient?

Monitor for any adverse reactions Signup and view all the answers

What is the primary purpose of monitoring APTT in patients undergoing Heparin therapy?

To monitor the therapeutic range of anticoagulation Signup and view all the answers

Which of the following statements about PT and INR in Coumadin therapy is correct?

Therapeutic INR typically ranges from 2.0 to 3.0. Signup and view all the answers

What is the expected white blood cell (WBC) count for a healthy adult?

5,000-10,000 cells/ml Signup and view all the answers

Which of the following is a significant precaution before performing a thoracentesis?

Informed consent must be obtained. Signup and view all the answers

Which procedure requires that patients might need to avoid voiding before the test?

Amniocentesis Signup and view all the answers

What should be considered when administering oxygen therapy to a patient with chronic respiratory illnesses?

Oxygen should not exceed more than 1-2 L/min. Signup and view all the answers

Which is NOT a sign that a patient may require restraints?

A clear consent from the patient. Signup and view all the answers

What is the correct protocol for the use of PPE?

Always used when there's potential exposure to infectious material. Signup and view all the answers

Which of the following is a vital consideration when using a lift for transporting a patient?

The base of the lift should be spread for stability. Signup and view all the answers

How often should the patient's circulation distal to restraints be checked?

Every 15-30 minutes. Signup and view all the answers

In the management of wounds, which type of healing typically forms a less prominent scar?

Primary intention. Signup and view all the answers

What is the main reason for checking breath sounds every shift in patients on oxygen therapy?

To monitor for changes in respiratory status. Signup and view all the answers

What is an appropriate consideration before using any restraint?

The least restrictive measure that works should be used. Signup and view all the answers

What safety measure should be taken with oxygen therapy to prevent fire hazards?

It's important to ensure no smoking signs are visible. Signup and view all the answers

When repositioning a patient in bed, how should the caregiver position them?

Place the patient on their stronger side for safety. Signup and view all the answers

What is the normal value range for Blood Urea Nitrogen (BUN) that indicates proper kidney function?

10-20 mg/dl Signup and view all the answers

What consequence might elevated triglyceride levels greater than 400 mg/dl indicate?

Risk of heart disease Signup and view all the answers

Which of the following factors can raise potassium levels above the normal range of 3.5-5.0 mEq/L?

Kidney impairment Signup and view all the answers

Which statement about administering oxygen via nasal cannula is correct?

It should not exceed 6 liters per minute. Signup and view all the answers

What is an appropriate guideline for preparing a patient for a triglyceride test?

NPO for 12-14 hours after a low fat diet Signup and view all the answers

What is an appropriate action to take when using a non-rebreather mask?

Ensure the mask fits snugly to prevent escape of oxygen. Signup and view all the answers

Which of the following is true regarding the delivery of oxygen in an oxygen tent?

It should provide a constant temperature of 70 degrees. Signup and view all the answers

When assessing a patient for myocardial infarction, what is the primary risk indicated by LDL levels exceeding 180 mg/dl?

Heightened risk for heart disease Signup and view all the answers

Which intervention should be performed prior to applying a wound dressing with W-D?

Cleanse the wound Signup and view all the answers

What is a sign of oxygen toxicity?

Substernal chest pain Signup and view all the answers

What is the potential effect of smoking and alcohol consumption on HDL levels?

Decrease HDL levels Signup and view all the answers

What is a critical aspect of monitoring a patient using an Ambu bag?

Ensure 100% oxygen is used with a reservoir. Signup and view all the answers

When conducting patient hygiene to prevent infection, which is most critical?

Handwashing before and after client contact. Signup and view all the answers

What is considered a critical elevation for triglycerides?

400 mg/dl Signup and view all the answers

In the context of isolation precautions, which of the following is required for respiratory transmission?

Masks should be used. Signup and view all the answers

What action should be taken after cleansing a wound before placing a new dressing?

Document the condition of the wound Signup and view all the answers

What is the normal sodium value range that indicates proper electrolyte balance?

135-145 mEq/L Signup and view all the answers

Which is an appropriate practice for collecting a urine sample?

Use the mid-stream method for clean catch. Signup and view all the answers

What action is required when a patient has received an intravenous pyelogram (IVP)?

Ensure the patient is positioned flat for 8 hours post-test. Signup and view all the answers

What is essential to confirm prior to a test requiring contrast media?

Ensure no allergies to iodine. Signup and view all the answers

Study Notes

Irrigation Principles

Irrigation solution flows from least contaminated to most contaminated.
Cleanse in direction of least contaminated to most contaminated.
Use a syringe alone or a syringe with an IV catheter or needle.
Use a collection device to catch irrigation fluid.
Wash hands before and after procedure.
Protect yourself with PPE (personal protective equipment).

Tracheostomy Care

Suction before irrigating the cannula.
Procedure is sterile.
Do not remove the outer cannula—only the inner cannula.
Place the patient in Semi-Fowler’s position.
Rinse inner cannula with sterile saline after cleaning with peroxide.
Remove only one side of the cotton tie at a time when changing ties ensuring the tracheostomy tube remains stabilized.
Tie is located at the side of the neck.
Auscultate lung sounds afterwards.
Ensure good oral hygiene.

Suctioning

Nasopharyngeal/Tracheal suctioning is sterile.
Oropharyngeal suctioning is clean.
Suction only when the catheter is coming out.
Assess respiratory status before and after suctioning.

Urinary Catheterization

Procedure is sterile.
Insert the catheter past the point of getting urine.
Inflate the balloon after insertion.
Do not kink the tubing.
Make sure there are no dependent loops.
Do not allow the client to lie on the tubing.
Do not allow the drainage bag to go above the bladder.
Use the port to obtain a specimen using a needle and syringe.
Empty the drainage bag at the end of a shift.
Assess for bladder distention when there is no output in the catheter or after removal.
Use a large drainage bag for nighttime.
Change the drainage bag every month.

Urine Collection Types

24-hour urine collection: Collect all urine for 24 hours and keep it on ice. The client should empty their bladder and discard the urine at the beginning of the collection period. The client should also empty their bladder and keep the urine at the end of the collection period.
Midstream urine collection: Clean the area, void a little bit, then collect in a cup.
Indwelling urinary catheter collection: Clean the port with alcohol prep and use a needle/syringe to collect urine. May need to clamp the tubing for no longer than 30 minutes.

Enemas

Procedure is clean.
Types of enemas: fleets, retention, SSE, TWE, carmative.
Place patient in left Sims' position.
The temperature of the enema fluid should be no higher than 105 degrees Fahrenheit.
Do not put soap in the enema solution until the water is completely in.
Do not hang the enema bag more than 18 inches above the patient.
Usually, no more than 3 enemas can be administered without a doctor's permission.
It's essential to review the procedure before administering an enema.

NG Tube Insertion

Patient should be in an upright position.
Always check placement and residual – follow orders.

Restrictive Restraints

Must have a doctor's order.
Use the least restrictive restraint that works.
Not a first-line intervention.
Check every 15-30 minutes; release, toilet and exercise every 2 hours.
Obtain informed consent from the patient or their legal representative.
Check circulation distal to the restraints.
The client can refuse restraints; assess their mental function; notify the doctor and responsible party, and document the refusal.

Patient Transfers

Use a Hoyer lift.
Lock the lift before using.
Make sure the base of the lift is spread wide.
Place the client in the center of the sling.
Reassure the client during the transfer.
Get training and plenty of help – do not use the lift alone.

Bed Positioning

Lock the wheels on the bed.
Position the bed closest to the client’s stronger side.
Do not secure any tubing to movable parts.

Oxygen Therapy

Odorless, tasteless, colorless, non-flammable gas (it supports combustion).
The flow meter regulates the rate of oxygen flow; FiO2 is the percentage of the concentration of oxygen.
Oxygen is usually ordered in liters per minute (L/M).
Chronic respiratory illnesses require lower settings of oxygen delivery (usually no more than 1-2 L/M).
Long-term use of oxygen requires humidification.
Ensure "NO SMOKING" signs are present and enforced.
Know the location of fire extinguishers.
Never use grease, oil, vaseline, alcohol, ether, or ungrounded equipment around oxygen.
Check breath sounds every shift and oxygen saturation every 4 hours.

Oxygen Delivery Methods

Nasal Cannula (BNP or BNC):
Fits into the nares.
Concentrations of 24-44%.
Delivery is no more than 6 liters.
Turn on oxygen before placing on the patient.
Tubing goes over the ears (may want to pad this area).
Provide nares care.
Assess and document the skin condition around the nares and ears.
Use water-soluble lubricant (lubrication).
Face Mask:
Allows more control over lower oxygen levels.
Concentration of 60-100% (6-10 liters) – depending on L/M.
A fine mist should be visible with humidified oxygen.
Adjust the mask so it fits snugly over the nose and covers the chin.
The reservoir should never completely collapse. If it does, oxygen should be turned up at the doctor’s order.
Types of Masks: - Venturi masks: 4-10 L/M, 24-55% oxygen delivery – very precise amounts. - Non-rebreather masks: 6-15 L/M, up to 100% oxygen delivery. - Simple masks: 5-8 L/M, 35-55% oxygen delivery.
Oxygen Tent:
Fine mist, constant temperature, high concentration of oxygen.
The canopy should enclose the patient's upper torso.
Keep the patient dry and prevent chilling.
Change linens more frequently.
Maintain a temperature inside the canopy of 70 degrees.
Adjust oxygen flow rate to 10-12 L/M.
Tuck the sides of the canopy under the mattress.
Parents may have to get under the tent to keep the child under the tent.
Hyperbaric Chamber:
Delivers 100% oxygen at 3 times atmospheric pressure.
Helps regenerate new tissue at a faster rate.
Ambu bag:
Up to 100% oxygen concentration depending on the presence of a reservoir.
The mask must firmly cover the mouth and nose to form a seal.
Deliver a breath every 5 seconds.
The Ambu bag can be attached to an endotracheal tube (ET tube).

Oxygen Toxicity

Seen more in concentrations over 50% for longer than 24-48 hours.
Signs and symptoms:
Nonproductive cough.
Substernal chest pain.
Nasal stuffiness.
Nausea and vomiting (NV).
Fatigue.
Headache.
Sore throat.
Hypoventilation.
Ensure oral hygiene and hydration.
Encourage TCDB (turn, cough, deep breathe).
Provide humidification.

Fire Safety

Follow RACE (Rescue, Alarm, Contain, Extinguish) and PASS (Pull, Aim, Squeeze, Sweep) protocols.

Fall Prevention

Monitor patients at risk for falls more closely.
Use call lights, brakes, and side rails appropriately.
Teach home safety:
Grab bars in the bathroom.
Avoid the use of rugs.
Keep floors clutter-free.
Use a night light.

Infection Control

Handwashing: The single most important way to prevent transmission of pathogens – Before and after client contact.
Isolation:
Contact: Gloves, gown, goggles, mask.
Enteric: Gloves, gown.
Respiratory (droplet/airborne): Mask.
Cycle of infection: pathogen, reservoir, portal of exit, mode of transport, portal of entry, host.

Sterile Technique

Sterile to sterile only.
When in doubt, it is contaminated.
Review sterile techniques.

Documentation

Factual, subjective, objective.
Rules of charting:
Accurate, concise, pertinent.
Complete and current.
Organized and timely.
Use only symbols/abbreviations approved by the facility.
Correct spelling and English.
Documentation is about the client and his/her condition.
Good penmanship, punctuations (ink only, no white-out, mistakes-1 line through and "error").

Communication

Verbal: Includes spoken and written.
Nonverbal: Check for congruency.
Avoid false hopes or clichés.
Acknowledge the client’s feelings/concerns.
Special situations:
Confused/agitated: Calm, approach slowly.
Blind: Don't “sneak up” on them.
Hearing impaired: Don't raise your voice, face them when talking, speak clearly and distinctly.

Diagnostic Tests

Non-invasive: Do not require a consent form (e.g. CXR, hand, ankle, leg X-rays).
Invasive: Require informed consent (e.g. bone marrow biopsy, IVP).
Do not require special preparation (e.g. X-rays).
Require special preparation:
NPO (nothing by mouth) after midnight:
Barium studies, colonoscopy, bronchoscopy, EGD (esophagogastroduodenoscopy).
Bowel prep: Colonoscopy.
Force fluids: After IVP, pelvic/OB ultrasounds.
Fasting: Blood sugar, cholesterol tests, triglycerides.

Radiology Tests

X-rays: Determine pregnancy (last menstrual cycle), remove jewelry or clothing with metal in the area being tested, hold breath during the procedure.
Bone Marrow Biopsy: Consent form, CBC (complete blood count) prior to the test, local anesthetic, iliac crest (most common site), pressure dressing to monitor for bleeding and signs of shock.
Intravenous Pyelogram (IVP): Examines the kidneys, check for allergies to iodine, do before barium studies, NPO after midnight, may require a laxative pre-test, force fluids post-test. Obtain consent from the patient for the procedure. Respiratory difficulties after the injection of dye may indicate an anaphylactic reaction.
Arteriograms: Consent, assess allergies to dye, keep the patient flat for 8 hours post-test with the affected extremity extended, force fluids post-test, monitor insertion site for bleeding, do not remove pressure from the site (feel under the extremity for bleeding).

Lab Tests

Venipuncture: Explain the procedure to the patient, protect yourself (use gloves and PPE), get help as indicated, ensure the skin is cleaned appropriately, verify the correct collection tube and order of draw, release the tourniquet before removing the venipuncture needle, apply pressure to the site post-test.
Endoscopic Procedures: Use a lighted instrument to directly view internal structures, require informed consent. NPO before and after. Vital signs every 30 minutes until stable. Monitor for respiratory distress with bronchoscopy, bleeding if polyps are removed with colonoscopy.
Urine Specimen Collection: Do not touch the inside of the container, label the container, not the top. Midstream collection requires cleaning the area, voiding a little, then collecting urine. Sterile urine collection can only be achieved with a catheter. If culture and sensitivity (C&S) and antibiotics are ordered, collect the specimen first. 24-hour urine collection requires discarding the first void, keeping all subsequent urine collections on ice, and if any urine is lost, starting the collection process over.
Blood Sugar Test: No special prep, elevations seen in gout, normal value: 3.0-7.0 mg/dl.
Creatinine: Assesses kidney function, elevations seen in kidney failure, normal level: 0.6-1.2 mg/dl.
Blood Urea Nitrogen (BUN): Assesses kidney function, elevations seen in dehydration and kidney impairment, normal level: 10-20 mg/dl.
Electrolytes:
Potassium: 3.5-5.0 mEq/L.
Sodium: 135-145 mEq/L.
Triglycerides: NPO for 12-14 hours, no alcohol for 24 hours prior to the test, high-fat ingestion up to 2 weeks before the test may elevate findings, normal values: Male- 40-160 mg/dl, Female - 35-135 mg/dl, values greater than 400 mg/dl are critical.
HDL: 30-80 mg/dl, lower the level, the greater the risk for heart disease, NPO for 12-14 hours, smoking and alcohol may lower levels.
LDL: 60-180 mg/dl, NPO for 12-14 hours, smoking and alcohol may elevate values.
VLDL: 25-50%, NPO.
Cholesterol Test: Fast 12-14 hours after eating a low-fat diet, no alcohol 24 hours prior to the test, normal values: Adult/elderly - less than 200 mg/dl.

Wound Care

Wet-to-dry dressings: Apply wet, allow to dry, used for wound debridement, discard wetting solutions after 24 hours, cleanse the wound before placing a new dressing.
Wound Irrigation: Gentle washing of an area with a stream of solution through an irrigating syringe. To prevent further tissue damage and introduction of bacteria. Promotes wound healing, comfort, cleansing, and medication administration.

Other Procedures

Sterile procedures: Performed by the provider, require informed consent, position according to procedure, monitor access site post procedure for bleeding and vital signs, monitor for respiratory distress with thoracentesis and hemoptysis, empty bladder with paracentesis and amniocentesis.
Ultrasound: Uses sound waves that bounce off solid structures to produce an image, most be done before barium studies or after a post-barium laxative has been effective, non-invasive, most patients must be NPO except with echocardiogram and pelvic exams.
Complete Blood Count (CBC): No special preparation, WBC- 5000-10,000, RBC- 4.2-6.1 million (males), 4.2-5.4 million (females), HCT - 42-52% (males), 37-47% (females), Hgb - 14-18 g/100ml (males), 12-16 g/100ml (females), Platelets - 150,000-400,000.
Coagulation Studies:
APTT: Used to monitor heparin therapy, therapeutic range is 1.5-2.5 times the control or normal range, normal 60-70 seconds.
PT: Used to monitor Coumadin therapy, therapeutic range is 1.5-2.0 times the control or normal range, normal 11.5-12.5 seconds.
INR: Used in conjunction with PT for clients on Coumadin, therapeutic ranges are from 2.0-3.0 depending on the client's problem.
Glycosylated Hemoglobin (HbA1c): Gives an accurate picture of blood sugar levels over the previous 120 days, can be drawn at any time, no special prep, elevated with diabetes mellitus, normal values: 4-7% (adults), 1.8-4% (children), poor diabetic control - 10-20%.

Hypoglycemia

Recheck blood sugar frequently to make sure it is remedied.
Treat hypoglycemia with any of the following:
Orange juice or other fruit juice.
Hard candy or honey.
Commercial glucose.
Glucagon by SC (subcutaneously), IM (intramuscularly) or IV (intravenously).
Glucose 10% or 50% IV.

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