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Questions and Answers

Which type of cholesterol helps cleanse blood vessels of fatty deposits?

Triglycerides

Very-Low Density Lipoprotein (VLDL)

Low-Density Lipoprotein (LDL)

High-Density Lipoprotein (HDL) (correct)

What is the impact of sodium on cardiovascular health?

It has no effect on hypertension.

It decreases fluid retention and heart workload.

It causes fluid retention, increasing heart strain. (correct)

It leads to decreased respiratory distress.

Which dietary approach is recommended for managing diabetes?

Eat large meals with concentrated carbohydrates.

Avoid monitoring blood glucose levels.

Maintain a diet of moderate complex carbohydrates. (correct)

Consume a high amount of simple sugars.

What adverse effect does trans-fat have on cardiovascular health?

It contributes to increased levels of triglycerides. Signup and view all the answers

What is a common sign of dysphagia?

Coughing while drinking Signup and view all the answers

Which population is considered high risk for developing Type 2 Diabetes Mellitus?

Native Hawaiians Signup and view all the answers

What is an essential consideration for managing HIV/AIDS-related muscle wasting?

Increasing calorie and protein intake. Signup and view all the answers

Which of the following food sources is recommended to help lower cholesterol levels?

Vegetable oils and fish Signup and view all the answers

Which of the following patient conditions is most likely to require Total Parenteral Nutrition (TPN)?

Inflammatory bowel disease Signup and view all the answers

What is the primary reason for administering TPN slowly at first?

To allow the body to adjust to high glucose concentration Signup and view all the answers

What should be monitored every shift while a patient is on PPN?

Patients' tolerance and response Signup and view all the answers

Why is it important to rotate the external disk at the insertion site daily?

To prevent sticking and irritation to the skin Signup and view all the answers

What is a critical step if residual fluid is greater than 500 ml before further feeding?

Document the finding and notify the RN or provider Signup and view all the answers

What potential complication can arise from a central line used for TPN?

Sepsis from infection Signup and view all the answers

Which of the following accurately describes Peripheral Parenteral Nutrition (PPN)?

Used for short-term nutritional support Signup and view all the answers

What action should be taken if the rate of a PPN infusion has been slowed?

Notify the healthcare provider Signup and view all the answers

How should the position of a patient receiving TPN be maintained during feeding?

Head of bed at 30 degrees Signup and view all the answers

Which of the following measures should be implemented daily while a patient is on TPN?

Monitor lab work Signup and view all the answers

What should be done if drug solution incompatibility is observed during IV infusion?

Look for white precipitations in the tubing, stop infusion, and flush the line. Signup and view all the answers

Which of the following best describes the recommended infusion rate for adults?

80 to 250 mL/hour. Signup and view all the answers

What must be done when the fluid remaining in the bag is less than 50 mL?

Hang a new bag. Signup and view all the answers

What is the primary goal of nutritional therapy?

To treat and manage disease. Signup and view all the answers

What type of diet is typically started when bowel sounds return post-surgery?

Clear liquid diet. Signup and view all the answers

Which of the following liquids is included in a clear liquid diet?

Coffee. Signup and view all the answers

Which IV solution is typically used to reduce edema?

5% dextrose in 0.45% saline Signup and view all the answers

What is a potential complication associated with large amounts of fluid infusion?

Fluid overload leading to CHF. Signup and view all the answers

What is a primary use of a controlled volume IV set?

To control fluid volume for pediatric patients Signup and view all the answers

Which group of patients is at greatest risk for aspiration during feeding assistance?

Patients with paralysis of the arms. Signup and view all the answers

Which of the following actions is crucial before inserting into an IV port?

Scrub the hub with a sterile alcohol swab Signup and view all the answers

What is the key assessment to perform when giving Total Parenteral Nutrition (TPN)?

Assess patient's weight gain and blood sugar levels. Signup and view all the answers

What type of tubing should be used for administering blood products?

Parallel or Y-tubing Signup and view all the answers

What form of diet provides a step between clear liquid and soft diet?

Full liquid diet. Signup and view all the answers

What is the first step if an adverse reaction occurs during a blood transfusion?

Stop infusion immediately Signup and view all the answers

Which contributing factor is commonly associated with obesity?

Genetics Signup and view all the answers

What is a key focus of nutritional counseling during pregnancy?

Managing maternal weight gain Signup and view all the answers

What is a common effect of substance abuse on nutrition?

Decreased financial resources for food Signup and view all the answers

What chronic disease is closely linked to obesity?

Cardiovascular disease Signup and view all the answers

Which sign might indicate a thiamine deficiency due to substance abuse?

Short-term memory issues Signup and view all the answers

What is an important nutritional intervention for preventing low-birth weight infants?

Nutritional counseling Signup and view all the answers

What dietary recommendation is made for individuals with substance abuse issues?

High-calorie, high-carb diet Signup and view all the answers

Which factor can contribute to the development of gestational diabetes?

Improper weight management during pregnancy Signup and view all the answers

What should be monitored in a patient with bulimia to identify potential complications?

Blood in output due to vomiting Signup and view all the answers

How does thiamine deficiency affect the cardiovascular system?

It can lead to symptoms of heart failure. Signup and view all the answers

What is a key consideration when administering medication to older adults?

They are at risk for dehydration and electrolyte imbalances. Signup and view all the answers

What is an important action to take after discovering a medication error?

Report it immediately to a supervisor. Signup and view all the answers

Which factor should nurses consider when calculating medication dosages for children?

Dosages should be based on age, size, and weight. Signup and view all the answers

Why is it important to color-code medications for older adults?

To accommodate for their limited vision. Signup and view all the answers

What may indicate non-compliance in older adults regarding medication intake?

Financial issues or experiencing side effects. Signup and view all the answers

What kind of precautions should be taken when an older adult is on long-term anti-inflammatory drugs?

Regular blood pressure assessments. Signup and view all the answers

What should nurses monitor to prevent risks when administering medications to older patients who have had a stroke?

Swallowing ability and pocketing of medication. Signup and view all the answers

What is a potential consequence of medication errors in healthcare?

Medication errors can lead to an elevated risk of death. Signup and view all the answers

Which of the following is a significant reason for involving parents when administering medication to children?

Parents provide comfort and ensure the child understands. Signup and view all the answers

What is a major risk association with anti-inflammatory drug use in older adults?

High probability of GI bleeding or anemia. Signup and view all the answers

What is the maximum volume that can be deposited in an intradermal injection?

0.1 mL Signup and view all the answers

Which of the following schedules indicates drugs with the highest potential for abuse and no accepted medical use?

Schedule I Signup and view all the answers

What is the appropriate technique for cleaning an injection site before administration?

Use circular motion from center outward Signup and view all the answers

What angle should the needle be inserted during an intramuscular injection?

90 degrees Signup and view all the answers

Which of the following drugs should never be crushed before administration?

Sublingual tablets Signup and view all the answers

What is the purpose of using aseptic technique during medication preparation?

To prevent contamination of medication Signup and view all the answers

What is a critical step to take when administering a high-risk drug?

Have one nurse double check the order Signup and view all the answers

What should be done if a patient has questions about their medication before administration?

Stop and investigate the patient's concerns Signup and view all the answers

What should be performed after administering medication to ensure its effects?

Reassess pain levels after 20-30 minutes Signup and view all the answers

What should be done before mixing two medications in a single syringe?

Check for compatibility Signup and view all the answers

What is a recommended duration for using certain medications to minimize the risk of addiction?

Less than 2 weeks Signup and view all the answers

What might be a symptom of withdrawal when discontinuing certain medications?

Restlessness Signup and view all the answers

What major muscle is responsible for moving air into and out of the lungs?

Diaphragm Signup and view all the answers

Which of the following is a reason older adults are at a higher risk for pneumonia?

Decreased total body water Signup and view all the answers

What is the primary function of alveoli in the lungs?

Gas exchange of CO2 and O2 Signup and view all the answers

What should patients be educated about concerning caffeine intake?

It may decrease effectiveness of sleep medications. Signup and view all the answers

Which of the following is a significant change in lung function due to aging?

Decreased elastic recoil Signup and view all the answers

In what way should controlled substances be handled within healthcare settings?

Never left in public areas Signup and view all the answers

What is the primary purpose of a pleural drainage system?

To remove air or fluid from the pleural cavity Signup and view all the answers

Which intervention is essential before inserting or removing a pleural drainage tube?

Medicate the patient for pain management Signup and view all the answers

What is an indicator of a potential air leak in a pleural drainage system?

Bubbling in the drainage system Signup and view all the answers

What specific action should be taken if a pleural drainage tube accidentally comes out?

Apply an occlusive Vaseline-based dressing Signup and view all the answers

What is the most significant consequence of inadequate sleep?

Impaired concentration and memory Signup and view all the answers

What type of sleep is characterized by high voltage, slow waves, and slowed respiratory and heart rates?

NREM Stage 3 Signup and view all the answers

Why is teaching patients to use an incentive spirometer essential post-operatively?

To reduce the risk of respiratory complications Signup and view all the answers

Which of the following objectives is part of Healthy People 2030 related to sleep?

Improve adult evaluations for sleep apnea symptoms Signup and view all the answers

What is the primary function of artificial airways?

To relieve airway obstructions Signup and view all the answers

When suctioning a patient, what is the maximum duration the suction catheter should be in place?

10 seconds Signup and view all the answers

What is a common consequence of prolonged use of endotracheal tubes?

Increased risk of vocal cord damage Signup and view all the answers

Which technique is used for airway suctioning to maintain a patent airway?

Sterile or aseptic technique depending on the situation Signup and view all the answers

What should be done before cleaning the inner cannula of a tracheostomy?

Suction the tracheostomy tube Signup and view all the answers

How should a patient be positioned while performing tracheostomy care?

In a high-fowlers position Signup and view all the answers

What sound indicates that a patient has inhaled too quickly with a metered-dose inhaler?

A harmonic-like sound Signup and view all the answers

What is the primary use of a tracheostomy?

To provide a secure airway for breathing Signup and view all the answers

Which of the following side effects is common to all non-benzodiazepine hypnotics?

Somnolence Signup and view all the answers

What should be monitored before administering a sedative to a patient?

Baseline vitals Signup and view all the answers

What is a crucial action to take if a patient experiences rebound insomnia after using Zaleplon?

Notify the healthcare provider Signup and view all the answers

Which instruction should be given to a patient taking Zolpidem?

Avoid drinking alcohol Signup and view all the answers

Which condition is characterized by decreased oxygen delivery to meet cellular needs?

Hypoxia Signup and view all the answers

What is the most common cause of airway obstruction?

Obstructed airway by the tongue Signup and view all the answers

How often should a patient's safety be reevaluated after administering a hypnotic?

After 1-2 hours Signup and view all the answers

What potential risk should be monitored in older adults taking sedatives?

Respiratory depression Signup and view all the answers

Which of the following conditions is associated with decreased neuromuscular function?

Multiple sclerosis Signup and view all the answers

What early sign indicates potential hypoxia in a patient?

Confusion Signup and view all the answers

Which of the following considerations should be made when caring for a patient at risk for injury due to drowsiness?

Raise side rails and keep call light in reach Signup and view all the answers

Which method is effective for clearing secretions from the lungs?

Huff coughing Signup and view all the answers

When should the respiratory rate and depth be assessed for a patient receiving a hypnotic medication?

Before administration Signup and view all the answers

What is a critical factor to ensure during postural drainage treatment?

Rhythmic clapping over thoracic area Signup and view all the answers

What is the primary role of oxygen therapy in patients with respiratory insufficiency?

Meeting oxygen needs Signup and view all the answers

Which factor is a common cause of disturbed diffusion in the lungs?

Fat emboli Signup and view all the answers

Which method of oxygen delivery allows for movement, eating, and talking?

Nasal Cannula Signup and view all the answers

What is a significant disadvantage of using a simple mask for oxygen delivery?

Requires high flow rates Signup and view all the answers

What is a key characteristic of a non-rebreather mask?

Utilizes a reservoir bag Signup and view all the answers

What does BIPAP specifically address in patients with COPD?

Two-way pressure support Signup and view all the answers

Which breathing technique helps COPD patients expel CO2 effectively?

Pursed breathing Signup and view all the answers

What is the primary risk associated with the long-term use of a partial rebreather mask?

Pressure necrosis Signup and view all the answers

Which oxygen delivery method provides precise control over oxygen concentration?

Venturi Mask Signup and view all the answers

What must be done to ensure effective use of a non-rebreather mask?

Monitor flow rates closely Signup and view all the answers

Which type of cholesterol is primarily responsible for increasing fatty deposits on vessel walls?

Low-Density Lipoprotein (LDL) Signup and view all the answers

What dietary modification can help lower blood pressure effectively?

Adopting a diet low in sodium and high in fruits Signup and view all the answers

What is the primary goal when managing blood glucose levels in individuals with diabetes mellitus?

Keeping blood glucose levels between 70-120 mg/dl Signup and view all the answers

What dietary approach is recommended for someone with HIV/AIDS experiencing muscle wasting?

Increased calorie and protein intake Signup and view all the answers

Which of the following conditions can lead to increased risk for fluid retention in patients with heart failure?

High sodium intake Signup and view all the answers

How should carbohydrates be consumed throughout the day by individuals managing diabetes?

Spread out over multiple meals Signup and view all the answers

Which of the following best describes a common sign of dysphagia?

Coughing while drinking Signup and view all the answers

What might a diet high in trans fats contribute to?

Increased levels of triglycerides Signup and view all the answers

What is the primary reason potassium should never be given as a bolus?

Incorrect administration can be fatal. Signup and view all the answers

Which complication of IV therapy is characterized by gas bubbles in the bloodstream?

Air embolus Signup and view all the answers

What clinical signs might indicate a patient is experiencing circulatory overload?

Dyspnea and crackles Signup and view all the answers

What immediate action should be taken if a patient is suspected of having speed shock?

Immediately stop the infusion. Signup and view all the answers

During IV therapy, which symptom is a classic sign of septicemia?

Fever and chills Signup and view all the answers

What is a critical intervention if catheter embolism is suspected?

Monitor vital signs and notify a healthcare provider. Signup and view all the answers

What should a nurse monitor for when managing a fluid overload situation in older patients?

Fluid output and vital signs Signup and view all the answers

In the event of an embolus, what should the nurse do first?

Call for help and position the patient properly. Signup and view all the answers

What is the primary reason for monitoring residual fluid in patients receiving feeding?

To prevent aspiration and determine feeding tolerance Signup and view all the answers

Which step is critical if a patient on TPN exhibits signs of a rapid infusion rate increase?

Stop the infusion immediately Signup and view all the answers

Which patient condition is most likely to require Peripheral Parenteral Nutrition (PPN)?

Patient with malnutrition but some oral intake Signup and view all the answers

What should be done if an infection is suspected at the central line site?

Notify the provider and maintain strict aseptic technique Signup and view all the answers

What is the maximum allowable volume for residual fluid before delaying further feeding?

500 ml Signup and view all the answers

What vital sign parameter must be monitored every 4-8 hours in a patient receiving PPN?

Blood glucose levels Signup and view all the answers

What complication can arise from leaving TPN solutions unrefrigerated for longer than 24 hours?

Sepsis due to bacterial infections Signup and view all the answers

Which of the following statements is true regarding the administration of TPN?

TPN should be started slowly and increased gradually Signup and view all the answers

What should be done when a patient has a large amount of drainage from a wound?

Draw a pen circle around the drainage on the dressing. Signup and view all the answers

When should a sterile technique be used in wound care?

For open or fresh surgical wounds. Signup and view all the answers

Which type of dressing should not be used on infected wounds?

Packing dressing. Signup and view all the answers

What kind of application is indicated for reducing inflammation?

Moist hot application. Signup and view all the answers

How often should a wet-to-damp dressing change be performed?

Every 4-6 hours. Signup and view all the answers

What should be observed in the IV solution when checking for incompatibility?

White precipitations in the tubing Signup and view all the answers

Which of the following is a key assessment when managing IV therapies?

Rate of the infusion Signup and view all the answers

When is it appropriate to start a clear liquid diet for a patient?

When bowel sounds return Signup and view all the answers

What is the recommended infusion rate for fluids in adults?

80 to 250 mL/hour Signup and view all the answers

Which population is generally at higher risk for aspiration during feeding assistance?

Older adults Signup and view all the answers

What should be done when less than 50 mL of fluid is remaining in an IV bag?

Hang a new bag of IV fluid Signup and view all the answers

What type of diet is positioned between a clear liquid and a soft diet?

Full liquid diet Signup and view all the answers

What is the primary purpose of retention sutures?

To relieve pressure on other sutures Signup and view all the answers

Which color of an open wound indicates that it is clean and ready to heal?

Red Signup and view all the answers

What type of drain works by gravity and capillary action to remove fluid from a wound?

Passive drain (Penrose) Signup and view all the answers

What type of suture is designed to be absorbed by the body and not require removal?

Absorbable sutures Signup and view all the answers

Which dressing technique is used immediately if a patient reports feeling like something has split open?

Apply a large sterile dressing soaked in normal saline Signup and view all the answers

What is the purpose of using Steri-Strips after sutures or staples are removed?

To hold the wound edges together and promote healing Signup and view all the answers

Which of the following statements is true regarding Dermabond?

It provides a seal and does not require a dressing. Signup and view all the answers

What is the recommended action if a drainage device is found to be 1/2 - 2/3 full at the end of a shift?

Empty it to ensure proper suction Signup and view all the answers

Before any nutritional tray is delivered to a patient, the nurse has the responsibility of:

confirming the diet on the tray with the diet sheet. Signup and view all the answers

Study Notes

IV Therapy

IVs are used when drugs/substances cannot be taken orally or rectally
IVs supply fluids, electrolytes (for dehydration), blood products (for anemia), medications (for low blood pressure), and nutritional components (like TPN)
IVs must be sterile
Assess for fluid overload. The average adult needs 1500-2000 mL of fluids daily to replace losses.
Fluid loss occurs through hemorrhage, dehydration, nausea & vomiting, diarrhea, profuse perspiration, fever, and drainage from wounds.
Monitor intake and output (I&O)
Monitor electrolyte levels (Sodium: 135-145, Chloride: 96-106, Potassium: 3.5-5.0)
All nurses must monitor IV flow rates.
Always check all IV orders for time limits, type, amount, and rate of infusion before administering or monitoring.
Know the proper administration set and catheter type for different solutions (e.g., blood, medications, TPN).
Be aware of patient's medical history and any allergies to prevent complications.
Be aware of drug interactions with ongoing medications.
Ensure proper sterile technique during insertion and maintenance to prevent infection.
Use appropriate tubing sizes based on the viscosity of the fluids administered (regular, macro, micro drops).

Types of IV Solutions

Isotonic: Has the same concentration as blood; fluid does not cause cell size change; used to expand blood volume. Examples include 0.9% Normal Saline, 5% Dextrose in water (D5W), and Ringer's Lactate (LR).
Hypertonic: Has a greater concentration than blood; fluid moves out of cells, shrinking them; used to replace electrolytes or decrease edema. Examples include 10% dextrose in water (D10W), 5% dextrose in 0.9% saline (D5 in 0.9 NS), 5% dextrose in 0.45% saline (D5 in .45 NS), and 5% dextrose in Ringer's lactate (D5LR).
Hypotonic: Has a lesser concentration than blood; fluid moves into cells, swelling them; used for cellular dehydration. Examples include 0.45% Normal Saline (1/2 NS)

IV Administration Sets

Primary Sets (Main Line): Used for solutions, tubing, and needleless connectors.
Secondary/Piggyback Sets: Used for medications to be added to an existing IV line.
Parallel IV Sets: Used for blood products, requiring a separate consent from the patient.
Controlled Volume Sets: Used for pediatric patients to control the rate of fluid delivery.

IV Tubing

Label tubing and verify with another nurse for high-risk medications. Monitor for over-infusion and under-infusion signs. Every 96 hours change the set (or per agency protocol to reduce infection risk).
Use appropriate tubing sizes based on the viscosity of the fluid being administered (regular, macro, micro drops).

Second/Piggyback Tubing

Used for antibiotics, antineoplastics, or blood products
The piggyback bag is placed higher than the primary line, using gravity for administration.
Always use a needleless system and ensure clamps are open.
Assess for adverse reactions from medications or drug incompatibility with the primary solution.
Always scrub the hub of ports with alcohol prior to inserting.

Parallel/Y Tubing

Used to administer blood concurrently with other IV fluids. Requires a separate consent from the patient.
Start with saline before blood to maintain IV access for emergency drugs.

Nurse Care for Patients Receiving Blood

Monitor for adverse reactions
Monitor vital signs frequently.
Assess for potential symptoms like chest pain, shortness of breath, itching, and back pain.
If any reaction occurs, stop the infusion immediately.
Remain with the patient during the blood transfusion.

Controlled Volume Sets

Used to deliver precise amounts of diluted medications over an extended period.
Prevents rapid fluid administration, and ensures controlled flow rates.

Fluid Overload

Excessive fluid intake or infusion can lead to circulatory overload, which may present with shortness of breath, crackles, increased breathing rate, moist cough, and abnormal cardiac function.

IV Administration Rate

Approximate rate: 1 mL/min, but can vary based on the individual and medical condition.

Complications

Hematoma: Blood accumulation in tissue surrounding the IV site (occurs more around first 48 hours). Signs are swelling, discoloration, resistance to flushing.
Phlebitis: Irritation of the vein from the IV catheter. Signs are redness, warmth, and swelling around the vein.
Infiltration: Solution leaking out of the vein and into the surrounding tissue. Signs are swelling, coldness, or blanching of the affected area. Apply cold compresses, do not massage the area.
Extravasation: Irritation of the tissue from leaking or infiltrated solution can lead to serious damage like infection or tissue necrosis. Notify the provider immediately!
Infection: Wound may be infected during surgery or post-op. Signs include increased pain, redness, warmth, purulent exudate.
Sepsis/Cellulitis: infection of tissue, potentially leading to systemic complications.
Dehiscence: Separation of layers of a wound, at risk within 3-5 days post op.
Embolism: A blood clot or air bubble lodged in blood vessel, potentially causing stroke/pulmonary issues.
Speed Shock: Rapid fluid administration.
Drug-Solution Incompatibility: Precipitate formation in the tubing, halt infusion.
Fluid Overload: Excessive fluid accumulated in the body.
Air Embolism: Air bubbles in the bloodstream.

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