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Questions and Answers
What should participants do regarding distractions during a Zoom class?
What is the appropriate attire for participating in an online class?
How should students engage with the speaker if they face technical issues?
What is the main purpose of the chat window during the Zoom class?
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What should a nurse prioritize after identifying a client's nursing diagnoses?
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What technique is recommended for safe suctioning of a client with a tracheostomy tube?
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What is one key guideline for maintaining respectful interactions during class?
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What should students do with their remarks in the chat window?
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Which intervention can help alleviate symptoms of GERD?
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What lab finding in a client diagnosed with dehydration requires immediate intervention?
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What position should a client be in for a lumbar puncture?
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Which assessment technique is NOT part of the abdominal assessment process?
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When palpating the abdomen, which area should be assessed first?
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What is the recommended fasting duration before a specimen collection test?
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What action should the nurse take if there are absent bowel sounds in a postoperative client?
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What is the best approach to assess for abnormalities in the abdominal region?
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What should be done to protect against infection during blood specimen collection?
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What is the purpose of labeling specimen containers with the client's information?
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Why should palpation be avoided in patients with Wilm's tumor?
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Which of the following statements about critical values is accurate?
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What should be done with the urine immediately at the start of a 24-hour collection period?
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Why should a 24-hour urine collection container be labeled?
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How should urine specimens be handled to avoid hemolysis?
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What is the first action a nurse should take after inserting an indwelling Foley catheter into a patient?
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What is the primary assessment the nurse should perform pre-procedure for a client scheduled for a CT scan of the kidneys?
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What type of test is the Mantoux test used for?
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What is the expected result of a positive Mantoux test?
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Which nursing key point is essential when preparing a client for a liver biopsy?
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What is the purpose of an ECG?
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What is the recommended position for a client during and after feeding with a nasogastric tube?
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Which of the following is NOT a purpose of total parenteral nutrition?
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What is the correct method for inserting a nasogastric tube?
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What is a key nursing intervention during the removal of a nasogastric tube?
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What should be done with the lid of the culture container before collecting a specimen?
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What is the correct procedure to prepare a client for expectoration?
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Which of the following intravenous access sites is most common for total parenteral nutrition?
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What position should the client be in during the insertion of a nasogastric tube?
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Study Notes
Abdominal Assessment
- Purpose: To determine the presence of mass, abnormal bowel sounds, lesions, and other abnormalities in the abdominal region.
- Nursing key points: IAPePa (Inspection, Auscultation, Percussion, Palpation)
- Position: Dorsal Recumbent
- Start palpating from RLQ, RUQ to LUQ, to LLQ
- Do not palpate patients with Wilm's tumor and abdominal Aortic Aneurysm
24-Hour Urine Specimen
- Collect using standard precautions to protect against exposure to blood or other body fluids and use strict aseptic technique to protect the client from infection.
- Label specimens with the client's name, date, exact time of collection, and type of specimen
- On laboratory requisition slip, note client identifying information as per agency policy, possible diagnosis, and test (or tests) being requested; record any factors that could interfere with results, such as foods or prescribed drugs.
- Avoid shaking blood specimens to avoid hemolysis and send promptly to the lab
- Values that fall within the laboratory reference range are considered normal
- Critical (panic) values are abnormal results that could increase risk of harm to the client; these are sent immediately to nursing unit and must be reported to the charge nurse and/or healthcare provider
Gastric Analysis
- Purpose: To collect gastric contents to help diagnose a variety of conditions involving the digestive system.
- Nursing Key points: Empty the stomach before collection, Use standard precautions to protect against exposure to blood or other body fluids and use strict aseptic technique to protect the client from infection.
Nasogastric Tube
- Purpose: Gavage (Feeding), Lavage (irrigation), Decompression, Medication.
- Nursing Key points:
- Feeding: Semi Fowler during and after feeding until 30 minutes.
- Removal: Semi Fowler (Hold breath while being removed).
- Insertion: High Fowler/ Sitting (Head is hyper extend, flex and lean forward).
- Ask to swallow if possible when inserting.
- Rubber Tubing- submerge into ice/ cold H20
- Plastic: KY Jelly
Total Parenteral Nutrition
- Purpose: Provides nutrition intravenously.
- Intravenous ACCESS: Central - most common site
- SUBCLAVIAN VEIN (Primary)
- Jugular Vein
- Insertion: Site should be lower than the body (Trendelenburg ) to avoid Pulmonary Embolism.
- Removal: Same Position + Valsalva Maneuver
- Purpose:
- IBD
- Severe Burns
- Malnutrition
- Pancreatitis
- Complications:
- Air embolism, Bloodstream Infection, Clot at the insertion site, Pneumothorax
Chest X-ray
- Purpose: To evaluate the lungs, heart, and surrounding tissues for abnormalities. This can help diagnose and monitor conditions like pneumonia, heart failure, and lung cancer.
- Nursing Key points:
- Instruct client to remove jewelry and metal objects from the chest area.
- Provide the client with a gown to wear.
- Ensure the client is calm and positioned correctly for optimal imaging.
- Inform the client that they need to hold their breath during the x-ray.
Cystoscopy
- Purpose: A cystoscopy is a procedure that allows a doctor to examine the inside of the bladder and urethra using a thin, telescope-like instrument called a cystoscope. This procedure helps diagnose and treat conditions such as urinary tract infections (UTIs), bladder cancer, and kidney stones.
- Nursing Key points:
- Explain the procedure to the client and answer any questions they may have.
- Obtain informed consent from the client.
- Monitor vital signs before, during, and after the procedure.
- Administer pain medication as prescribed.
- Instruct the client to drink fluids after the procedure to help flush out the bladder.
CT scan
- Purpose: A CT scan, also known as a CAT scan, is a medical imaging technique that uses X-rays to take cross-sectional pictures of the inside of the body. This allows doctors to view organs, bones, and other structures in detail. It`s commonly used to diagnose and monitor a variety of conditions, including cancer, heart disease, stroke, and traumatic injuries.
- Nursing Key points:
- If a contrast medium is being used, assess the client for allergies to iodine or shellfish.
- Ensure the client has removed any metal objects from the examination area.
- Provide the client with instructions regarding the need to stay still during the scan.
CVP (central venous pressure) monitoring
- Purpose: Assessing the patient's fluid volume status. The CVP catheter is often used to administer intravenous (IV) fluids, medications, and blood products.
- Nursing Key points:
- Use sterile technique during the procedure to prevent infection.
- Monitor vital signs closely throughout the procedure.
- Clean the insertion site regularly to prevent infection.
- Observe for signs of complications, such as bleeding, infection, and air embolism.
Electrocardiogram (ECG)
- Purpose: To evaluate the electrical activity of the heart. An ECG can help diagnose a variety of heart conditions, such as arrhythmias, heart attacks, and heart failure.
- Nursing Key points:
- Ensure the client is lying down comfortably in a supine position.
- Clean the skin where the electrodes will be placed.
- Apply the electrodes to the client's chest and limbs in the correct positions.
- Obtain a clear ECG tracing.
Electroencephalogram (EEG)
- Purpose: An EEG, which stands for electroencephalogram, is a test that measures the electrical activity in your brain. It can help diagnose conditions that affect your brain, such as epilepsy, brain tumors, and sleep disorders.
- Nursing Key points:
- Ensure the client's hair is clean and free of oils or products.
- Explain the procedure to the client and answer any questions they may have.
- Ensure the client is comfortable and lying down in a quiet, dim room.
- Ask the client to remain still and avoid talking during the test.
Fasting Blood Sugar (FBS)
- Purpose: To assess blood glucose levels in a fasting state.
- Nursing key points:
- Instruct the client to fast for 8-12 hours prior to the test.
- Ensure the client has avoided any food or drink (except water) during the fasting period.
- Collect blood samples from the appropriate site, following the agency´s standard protocol.
- Document the time of collection and the client's fasting status.
Intravenous Pyelography (IVP)
- Purpose: IVP is a medical imaging test that uses X-rays and contrast dye to make clear pictures of your kidneys, ureters, and bladder. It can help diagnose and monitor a variety of conditions affecting the urinary tract, such as kidney stones, kidney infections, and bladder cancer.
- Nursing key points:
- Assess for allergies to iodine, shellfish, or contrast dye.
- Ensure the client is adequately hydrated before the procedure.
- Instruct the client to void before the procedure and administer medications as prescribed.
- Monitor the client for adverse reactions to the contrast dye.
Liver biopsy
- Purpose: A liver biopsy is a procedure in which a small sample of liver tissue is removed for examination under a microscope, typically to diagnose liver disease or monitor its progress.
- Nursing key points:
- Obtain informed consent from the client and explain the procedure.
- Monitor vital signs and observe for any signs of bleeding.
- Educate the client on the importance of resting after the procedure.
- Provide pain relief and monitor for complications such as infection or pain.
Mammography
- Purpose: A mammogram is a specialized type of X-ray that examines breast tissue, helping identify breast cancer early.
- Nursing key points:
- Explain the procedure to the client and answer any questions.
- Instruct the client to avoid using deodorant, antiperspirant, or powders on the day of the exam.
- Ensure the client is comfortable and positioned correctly for the procedure.
- Provide support and reassurance during the exam.
Mantoux Test
- Purpose: A Mantoux test is a skin test used to determine if a person has been infected with tuberculosis (TB).
- Nursing key points:
- The test is administered by injecting a small amount of tuberculin (a purified protein derived from Mycobacterium tuberculosis) into the skin of the forearm.
- The injection site is read 48-72 hours later.
- A positive test yields an induration (a raised, hardened area) of 10 mm or more.
- A negative test means the person is not infected with TB.
- A positive test does not mean the person has active TB, but it does indicate that the person has been exposed to TB and may require further testing or treatment.
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Description
Test your knowledge on abdominal assessment techniques and the proper collection of 24-hour urine specimens. Understand the key nursing points, including inspection, palpation methods, and the importance of accurate specimen handling. This quiz is essential for nursing students and professionals to ensure safe and effective patient care.
