Nursing Fundamentals Quiz

Restraints

• Doctor's order required
• Least restrictive method used first
• Not a first line intervention
• Check every 15-30 mins, release every 2 hours
• Signs consent
• Check circulation distal to restraints
• Client can refuse
• Notify doctor if client refuses
• Document refusal

Mechanical Lifts

• Lock before using
• Base of lift spread
• Client in center of sling
• Get training and help

Transfer Beds

• Lock wheels
• Place closest to client's stronger side
• Don't secure tubing to movable parts

Oxygen Therapy

• Odorless, colorless, non-flammable gas (supports combustion)
• Flow meter regulates O2 rate; FiO2 is concentration percentage
• Usually ordered in L/min
• Chronic respiratory illnesses require lower settings of O2 delivery, no more than 1-2 L/M
• Long term use requires humidification
• No smoking allowed, know extinguisher locations
• No oil, grease or flammable items near O2
• Breath sounds q shift, O2 sats q 4 hours

Nasal Cannula

• Documented as BNP or BNC
• Fits into nares
• Concentrations of 24-44%, no more than 6 L/M
• Turn O2 on before placing on patient
• Tubing goes over ears
• Nares care with water soluble lubricant

Face Mask

• Allows more control of O2 levels
• Concentrations 60-100% (6-10 L/M) depending on L/M
• Mist should be visible with humidified O2
• Mask fits snug over nose and chin
• Reservoir should not completely collapse
• Types: Venturi, Non-rebreather, Simple

Oxygen Tent

• Fine mist, constant temperature, high concentration
• Canopy encloses upper torso
• Keep patient dry and prevent chilling, change linens frequently
• Temperature inside should be 70°
• Adjust O2 flow to 10-12 L/M
• Tuck sides of canopy under mattress

Hyperbaric Chamber

• Delivers 100% O2 at 3 times atmospheric pressure
• Faster tissue regeneration

Ambu Bag

• Up to 100% concentration depending on reservoir
• Mask seals tightly over mouth and nose
• Breath delivered every 5 seconds
• Ambu bag can be attached to ET tube

O2 Toxicity

• Concentrations greater than 50% for more than 24-48 hours
• Non-productive cough
• Substernal chest pain
• Nasal stuffiness
• Nausea/vomiting
• Fatigue
• Headache
• Sore throat
• Hypoventilation

RACE

• Rescue
• Alarm
• Contain
• Extinguish

PASS

• Pull
• Aim
• Squeeze
• Sweep

Home Safety

• Monitor at-risk individuals more closely
• Use call lights, brakes, and side rails appropriately
• Teach home safety

Infection Control

• Handwashing is the most important way to prevent transmission
• Isolation depends on how the pathogen is spread
• 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

Charting

• Factual, subjective, and objective
• Accurate, concise, pertinent
• Complete and current
• Organized and timely
• Approved symbols/abbreviations
• Correct spelling and English
• Documentation is about client and their condition
• Good penmanship and punctuation
• Ink only, single line through errors

Communication

• Verbal - includes spoken and written
• Nonverbal - check for congruency
• No false hopes or cliches
• Acknowledge client's feelings/concerns
• Special situations: Confused/agitated, blind, hearing impaired

X-Ray

• Non-invasive
• No prep required
• No consent form required
• Determine pregnancy
• Remove jewelry and metal from area
• Hold breath during procedure

Bone Marrow Aspiration

• Consent required
• CBC prior to test
• Local anesthetic needed
• Iliac crest most common site
• Pressure dressing applied, watch for bleeding, signs of shock
• Tenderness at site expected

Intravenous Pyelogram (IVP) - Kidneys

• Check allergy to iodine
• Do before barium studies
• NPO after midnight
• May require laxative pre-test
• Force fluids post test
• Consent usually obtained by Radiology
• Respiratory difficulty after dye injection may indicate anaphylactic reaction

Arteriogram

• Consent required
• Assess allergies
• Keep client flat 8 hours post-test with affected extremity extended
• Force fluids post-test
• Monitor insertion site for bleeding
• Do not remove pressure from site
• Renal arteriogram, lung scan, and femoral angiogram

Venipuncture

• Explain procedure
• Protect yourself
• Get help as indicated
• Clean skin appropriately
• Correct collection tube and order of draw
• Release tourniquet before removing needle
• Apply pressure to site post test

Endoscopic Procedures

• Lighted instrument to view internal structures
• All require NPO post-midnight and consent
• Bowel prep for colonoscopy
• NPO after midnight for bronchoscopy and EGD until gag and swallow returned
• Vital signs post procedure every 30 mins until stable
• Monitor for respiratory distress with bronchoscopy
• Monitor for bleeding if polyps are removed (colon)

Urine Specimen Collection

• Don't touch inside of container
• Label container, not the top
• Mid-stream - clean, void a little, then collect
• Sterile - only real way is to catheterize
• If C&S and antibiotics are ordered, collect specimen first
• 24-hour urine - discard first, keep last and every amount in between, keep on ice

Invasive Procedures

• Sterile procedure performed by provider
• Informed consent
• Position according to procedure
• Monitor access site for bleeding and VS
• Monitor for respiratory distress or breath sounds with thoracentesis or hemoptysis
• Empty bladder with paracentesis and amniocentesis

Ultrasound

• Sound waves bounce off solid structures to produce an image
• Must be done before Barium studies or after post-Barium laxative
• Non-invasive
• Most patients must be NPO except for echocardiogram and pelvic

Complete Blood Count (CBC)

• No special prep
• WBC 5,000-10,000: Neutrophils, Basophils, Monocytes, Eosinophils, Lymphocytes
• RBC - 4.2-6.1 million (males), 4.2-5.4 million (females)
• HCT: 42-52% (males), 37-47% (females)
• Hgb: 14-18 g/100 mL (males), 12-16 g/100mL (females)
• Platelets: 150,000-400,000

Coagulation Studies

• APTT: Used to monitor Heparin therapy, therapeutic range 1.5-2.5 times control
• PT: Used to monitor Coumadin therapy, therapeutic range 1.5-2.0 times control
• INR used with PT for clients on Coumadin, therapeutic range 2.0-3.0

Blood Glucose

• 60-110 mg/dL (normal fasting levels)
• No special prep unless ordered fasting, then NPO overnight
• Fasting, Accuchek, Post-prandial

Glycosylated Hemoglobin

• Gives accurate picture of blood sugar levels over previous 120 days
• Can be drawn at any time, no prep needed
• Elevated with diabetes mellitus
• Normal values: Adult 4-7%, Child 1.8-4%, Poor diabetic control 10-20%

Gastric Tube Feeding

• Recheck blood sugar frequently, hold for more than 100 mL unless otherwise ordered
• Return residual to stomach
• Flush before and after
• Give bolus by gravity
• Monitor weight, breath sounds, I & O

Bathing

• No soap on face unless requested
• Rinse all soap from body
• Dry by patting
• Use long strokes toward heart

Assessments

• Includes pain and weight
• Know normal values
• Weights: Same scale, clothing, and time of day
• Pain: Always assess before and after medication; vital signs (except temp) are usually elevated with acute pain, narcotics more likely for acute pain; believe the patient

Med Administration

• 6 rights: Right patient, drug, dose, route, time, documentation
• Verify order
• Routes affect absorption
• Assess for allergies
• Instruct on drug, dose, route, purpose, special instructions
• Life threatening allergic reactions

Informed Consent

• Physician discusses risks, benefits, etc.
• Nurse witnesses signature
• Ensure questions are answered before signing
• Usually with invasive procedures

Incident Reports

• No report in nursing notes
• Documents unusual events
• Factual information only

Legal and Ethical Concepts

• Assault - intentional threat of bodily harm
• Battery - unlawful touching without consent
• Defamation: Slander (spoken), Libel (written)
• Tort - civil law concerning wrongs against a person or property

Client Rights

• Privacy and confidentiality
• Right to information
• Right to refuse treatment
• Right to adequate and competent care
• Right to have bill explained
• Right to confidentiality

Delegation

• Transferring authority to a competent individual to perform a task
• Accountability - responsible for actions of oneself or others
• Unlicensed Assistive Personnel (UAP) - any unlicensed personnel to whom nursing tasks are delegated
• Supervision

The Nursing Process

• Assessing
• Diagnosing
• Planning
• Implementing
• Evaluating

Five Rights of Delegation

• Right task
• Right circumstances
• Right person
• Right direction/communication
• Right supervision/evaluation

Delegation - General Principles

• Clear instructions initially and for periodic reassessment
• RNs can delegate to RNs, LPNs, and AP
• LPNs can delegate to LPNs and AP
• Only delegate tasks appropriate to educational level.
• RNs cannot delegate nursing process, client education, or tasks requiring nursing judgment

Factors Affecting Delegation

• Predictability of outcome
• Potential for harm
• Complexity of care
• Need for problem-solving
• Level of interaction with the client

Delegation - Factors Determining Competence

• Education, training, experience
• Knowledge and skill to perform task
• Level of critical thinking needed
• Communication ability
• Demonstrated competence
• Facility policies and procedures
• Licensing legislation

Cardiac Medications

• Positive inotropic activity (increases force of myocardial contraction)
• Negative chronotropic effect (slows conduction and decreases heart rate)
• Uses: Heart failure, atrial fibrillation

Cardiac Glycosides

• Side effects: Headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset, anorexia
• Lanoxin (digoxin): Loading dose, therapeutic level 0.8-2.0 ng/mL; toxicity green/yellow visual disturbances, anorexia, nausea, vomiting, changes in cardiac function; monitor potassium levels; Antidote digibind (digoxin immune)
• Primacor (milrinone lactate): IV only

Vasodilators

• Nitrates: Relax smooth muscles (vessels) increasing blood flow to myocardium
• Calcium Channel Blockers: Slow conduction, dilate coronary arteries, depress contractility of the heart

Nitrates

• Uses: Relieve angina pain, prevention of anginal attacks, treatment of chronic stable angina
• Side effects: Headache, dizziness, weakness, hypotension, flushing
• Examples: ISMO, Imdur (isosorbide mononitrate), Isordil (isosorbide dinitrate), Nitro-Bid, Nitrostat (nitroglycerin)

Calcium Channel Blockers

• Uses: Anginal pain, hypertension
• Side effects: Dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, cough
• Examples: Norvasc (amlodipine), Cardizem (diltiazem HCL), Plendil (felodipine), Cardene (nicardipine HCL), Procardia, Adalat (nifedipine), Calan, Isoptin (verapamil HCL)

Nitroglycerin Admin

• Give SL nitroglycerin 1 tablet every 5 minutes x3, call doctor if pain persists
• Monitor VS, take apical pulse
• Protect safety
• Monitor and document chest pain

Nitroglycerin Safety

• New bottle every 3 months
• Keep in brown bottle
• Rise slowly from lying or sitting position
• Nitro should tingle or sting when used
• Rotate patch sites, remove old
• Keep with you at all times

Antihypertensive Medications

• Uses: Hypertension, hypertensive emergencies, Pheochromocytoma
• Peripheral Vasodilators: Hypotension, dizziness, angina, headache, hirsutism, nasal congestion, fatigue, sodium and water retention
• Beta-blockers: CHF, dizziness, bradycardia, arrhythmias, decreased libido, impotence

Anti-Adrenergic Drugs

• Centrally acting: Drowsiness, sedation, headache, dry mouth, hypotension, syncope, fluid retention, constipation
• Peripherally acting: Headache, fatigue, hypotension, lethargy, dyspepsia
• Alpha-Adrenergics: Headache, fatigue, hypotension, sexual dysfunction, lack of energy

ACE Inhibitors

• Side effects: Nausea, cough, hypotension, headache, fatigue
• Examples: '-pril' drugs

Angiotensin II Receptor Antagonists

• Side effects: Diarrhea, abdominal pain, hypotension, fatigue, headache, lightheadedness, URI symptoms, cough.
• Examples: '-sartan' drugs

Hypertensive Emergency Drugs

• Side effects: Dizziness, weakness, nausea/vomiting, sodium and water retention, apprehension, headache
• Examples: Hyperstat (diazoxide), Nitropress (Nitroprusside sodium)

Antihypertensive Medication Administration

• Take BP before giving medication
• Monitor for adverse effects
• I&O
• Dangle before getting out of bed

Antihypertensive Medication Safety

• Don't stop abruptly
• Report adverse effects
• Take as directed
• Follow up care
• Report HF s/s (weight gain, swelling, SOB)
• Don't use OTC cold preparations without clearing with physician

Cardiac Glycosides

• Increase cardiac output, slow heart rate, and decrease conduction
• Used for heart failure and atrial fibrillation
• Adverse effects include headache, weakness, drowsiness, visual disturbances, arrhythmias, GI upset, and anorexia
• Lanoxin (digoxin)
  • Requires a loading dose
  • Therapeutic drug level is 0.8-2.0 ng/mL
  • Toxicity symptoms include green/yellow visual disturbances, anorexia, nausea, vomiting, and changes in cardiac function
  • Monitor potassium levels as hypokalemia predisposes to digoxin toxicity
  • Antidote: Digibind (digoxin immune)
• Primacor (milrinone lactate)
  • IV administration only

Vasodilators

• Relax smooth muscles in vessels, increasing blood flow to the heart
• Nitrates
  • Used to relieve pain associated with angina, prevent anginal attacks, and treat chronic stable angina
  • Adverse effects include headache, dizziness, weakness, hypotension, and flushing
  • Examples: ISMO, Imdur (isosorbide mononitrate); Isordil (isosorbide dinitrate); Nitro-Bid, Nitrostat (nitroglycerin)
• Calcium Channel Blockers
  • Slow conduction, dilate coronary arteries, and depress contractility of the heart
  • Used for angina and hypertension
  • Adverse effects include dizziness, lightheadedness, fatigue, nausea, constipation, peripheral edema, hypotension, bradycardia, nasal congestion, and cough
  • Examples: Norvasc (amlodipine); Cardizem (diltiazem HCL); Plendil (felodipine); Cardene (nicardipine HCL); Procardia, Adalat (nifedipine); Calan, Isoptin (verapamil HCL)

Nitroglycerin Administration

• Give sublingual nitroglycerin 1 tablet every 5 minutes for a maximum of 3 tablets
• If pain persists after 3 tablets, contact the physician
• Monitor vital signs, including taking an apical pulse
• Ensure patient safety and document chest pain

Nitroglycerin Safety

• Obtain a new bottle every 3 months
• Store nitroglycerin in a brown bottle
• Rise slowly from a lying or sitting position to prevent orthostatic hypotension
• Nitroglycerin should tingle or sting when used
• Rotate patch sites, removing the old patch before applying a new one
• Keep nitroglycerin with you at all times

Antihypertensive Medications

• Used for hypertension, hypertensive emergencies, and diagnosis of pheochromocytoma (alpha-adrenergic blocking drugs)

Antihypertensive Drug Classes

• Peripheral Vasodilators
  • Adverse effects include hypotension, dizziness, angina, headache, hirsuitism, nasal congestion, fatigue, and sodium and water retention
  • Examples: Apresoline (hydralazine HCL); Loniten (minoxidil)
• Beta Blockers
  • Adverse effects include CHF, dizziness, bradycardia, arrhythmias, decreased libido, impotence, and constipation/diarrhea
  • Examples: Tenormin (atenolol); Lopressor, Toprol (metoprolol); Corgard (nadolol); Inderal (propanolol); Blocadren (timolol maleate)
• Antiadrenergic Drugs (Centrally Acting)
  • Adverse effects include drowsiness, sedation, headache, dry mouth, hypotension, syncope, fluid retention, and constipation
  • Examples: Catapres (clonidine HCL); Tenex (guanabenz acetate); Aldomet (methyldopa)
• Antriadrenergic Drugs (Peripherally Acting)
  • Adverse effects include headache, fatigue, hypotension, lethargy, dyspepsia, and headache
  • Examples: Cardura (doxazosin); Ismelin (guanethidine monosulfate)
• Alpha-Adrenergic Blockers
  • Adverse effects include headache, fatigue, hypotension, sexual dysfunction, and lack of energy
  • Examples: Regitine (phentolamine)
• ACE Inhibitors (pril drugs)
  • Adverse effects include nausea, cough, hypotension, headache, and fatigue
  • Examples: Lotensin (benazepril HCL); Capoten (captopril); Vasotec (enalapril); Mavik (trandolapril); Zestril (lisinopril)
• Angiotensin II Receptor Antagonists (sartan drugs)
  • Adverse effects include diarrhea, abdominal pain, hypotension, fatigue, headache, lightheadedness, URI symptoms, and cough
  • Examples: Atacand (candesartan cilexetil); Avapro (irbesartan); Cozaar (losartan potassium); Micardis (telmisartan); Diovan (valsartan)
• Hypertensive Emergency Drugs
  • Adverse effects include dizziness, weakness, nausea/vomiting, sodium and water retention, apprehension, and headache
  • Examples: Hyperstat (diazoxide); Nitropress (nitroprusside sodium)

Antihypertensive Nursing Considerations

• Measure blood pressure before administering medication
• Monitor for adverse effects
• Monitor intake and output
• Dangle the patient's legs before getting out of bed to prevent orthostatic hypotension

Antihypertensive Patient Teaching

• Do not stop medications abruptly
• Report any adverse effects to the physician
• Take medications as directed
• Attend follow-up appointments
• Report any signs and symptoms of heart failure (sudden weight gain, swelling, shortness of breath) to the physician
• Do not use OTC cold preparations without consulting with the physician

Test your knowledge on key nursing considerations, including the use of restraints, oxygen therapy, wound healing intentions, and patient positioning during procedures. This quiz covers essential safety measures and laboratory values relevant to nursing practice.