FON (Part 1-3) PDF

FON (PART 1) Sabina Identify the symbol given below? Laser radiation Corrosive Bio-Hazard symbol Identify the symbol given below? Biodegradable Recycling Which ministry is responsible for...

FON (PART 1) Sabina Identify the symbol given below? Laser radiation Corrosive Bio-Hazard symbol Identify the symbol given below? Biodegradable Recycling Which ministry is responsible for updating the guidelines of Bio- medical waste management in India? a. Central pollution control board b. Ministry of Environment, Forest and Climate Change c. Ministry of Health & Family Welfare d. Indian Council of Medical Research As per the 2016 rule of Biomedical waste management all of the following color code are the part of Biohazard except? a. Yellow b. Red c. Blue d. Black All of the following are the minor sources of biomedical waste, except: a. Vaccination center b. Blood donation camps c. Autopsy center d. Dentist clinics In which Biomedical Waste Bin the nurse will discard the following PPE illustrated in the given image? a. Yellow b. Red c. Black d. Blue Vacutainer filled with blood should be discarded in which of the following bin? a. Red b. Yellow c. Blue d. White Where will the physician discard the reusable PPE after the surgery? a. Red b. Yellow c. Blue d. Black Discard in blue cardboard box Select which of the following doesn’t met with the standard of deep burial for the disposal of biomedical waste? a. Pit should be 5 meter deep b. Half filled with waste & then covered with lime c. animals do not have any access to burial sites d. None of the above Which of the following statement is incorrect about yellow biomedical waste bag? a. Made of non-chlorinated plastic material b. Used Line, tubes and catheter are discarded c. Soiled linen, mattresses, are disposed of in the yellow bag d. Silver X-Ray films, discarded formalin, liquids from laboratories and cleaning floor is discarded in the yellow cover Following blood transfusion, blood bags are disposed which color coded bin? a) Red b) Yellow c) Blue d) White The nurse needs to discard the tablet methotrexate. Which biomedical waste bin the nurse will use to discard this tablet? a. Red bin b. Yellow bin with cytotoxic label c. Yellow bin d. Blue bin The final treatment of waste collected in puncture proof container? a. Incineration or deep burial b. Autoclaving then sent for recycling c. Disinfection or Autoclaving then sent for recycling d. Dry heat sterilize followed by shredding A student nurse is caring for a client with a Clostridium difficile infection. Which observation made by a registered nurse indicates that the student needs additional information about this disease? 1. Wearing gloves during a physical assessment 2. Entering the room without first putting on a mask 3. Performing frequent hand hygiene with an alcohol-based hand disinfectant 4. Wearing a gown while providing perineal care FON (Part 2) Sabina Contraindication of NG Tube Intubation POSITION METHOD TO CONFIRM THE PLACEMENT OF NG TUBE METHOD TO CONFIRM THE PLACEMENT OF NG TUBE Before FEEDING Continuous Feeding The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has ask the client to sip water through a straw. What is the purpose of this action? 1. To prevent dehydration 2. To divert the client’s attention 3. To close the epiglottis 4. To lubricate the tube After passing a nasogastric (NG) tube in an adult, the nurse checks for proper placement by doing which of the following? 1. Injecting air into the NG tube and listening with a stethoscope over the stomach for a “swoosh” 2. Putting the end of the NG tube in a glass of water and observing for bubbles 3. Asking the client if the tube is comfortable 4. Aspirating contents and checking the pH The nurse is to administer a tube feeding to a client. Before administering the feeding, what is essential for the nurse to do? 1. Ask the client if she feels full 2. Aspirate the nasogastric tube and check for acid 3. Change the tubing 4. Feel over the end of the tube and do not administer if air is felt The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? 1. “It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing.” 2. “The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism.” 3. “Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem.” 4. “The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis.” The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse? 1. Dry mouth 2. Weak muscles 3. Sore throat 4. Irritated nose The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the Post-operative nursing care unit, the drainage from the nasogastric tube is red. What is the nurse’s best response to this? 1. Report it immediately to the charge nurse or the physician 2. Record the finding and continue to observe 3. Immediately apply pressure to the operative site 4. Place the client in Trendelenburg position Two hours after admitting a client to a postsurgical unit following a nephrectomy, the client states feeling nauseated. A nurse notes minimal drainage from the nasogastric (NG) tube. Which action should the nurse take first? 1. Notify the physician 2. Administer an antiemetic medication listed on the client’s medication record 3. Pull the NG tube out about an inch to release it suctioning against the wall of the stomach 4. Irrigate the NG and check to see if the fluid returns to the drainage-collection container A nurse is planning to administer medications through a nasogastric (NG) tube. Which interventions should the nurse plan after checking the medications, checking client identification, and verifying tube placement? SELECT ALL THAT APPLY. 1. Crush together all medications that are acceptable for crushing 2. Pour crushed medications into one medication cup and mix with water 3. Withdraw all medications and water solution from the medication cup with a syringe and administer 4. Crush each medication separately 5. Pour each individual crushed medication into individual medication cups and mix with water 6. With a syringe, withdraw the single dose of medication from the medication cup and administer. 7. Flush the tubing with water between medications A nurse is performing an initial postoperative assessment on a client following upper gastrointestinal surgery. The client has a nasogastric tube to low, intermittent suction. To best assess the client for the presence of bowel sounds, the nurse should: 1. place the stethoscope to the left of the umbilicus. 2. turn off the nasogastric suction. 3. use the bell of the stethoscope. 4. turn the suction on the nasogastric tube to continuous A 24-year-old client with anorexia has had a nasogastric (NG) tube placed in preparation for intermittent enteral feedings. The nurse knows to do which of the following when administering medications via an NG tube? 1. Crush the enteric coated aspirin. 2. Mix the medications with the client’s feeding formula. 3. Flush the tube using a 15-mL syringe. 4. Administer each medication separately. A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications? 1. Confusion. 2. Muscle cramping. 3. Edema. 4. Tremors. The client with a nasogastric (NG) attached with suction machine has abdominal distention. Which of the following measures should the nurse do first? 1. Call the physician. 2. Irrigate the NG tube. 3. Check the function of the suction equipment. 4. Reposition the NG tube A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract: 1. Compression. 2. Lavage. 3. Decompression. 4. Gavage. Identify the image given below: a. Total parenteral nutrition bag b. Gravity enteral feeding bag set c. Urine flow meter d. Intravenous fluid pressure bag The patient who is on NG tube now can tolerate the soft diet. The doctor plans for his NG tube removal. While removing the NG tube which of the following instruction should be given to the patient? a. Perform the Valsalva maneuver b. Performed pursed lip exercise c. Inhale and exhale simultaneously d. Take a deep breath and hold it A BSc nursing student posted in medicine ward helping the morning shift nurses in their bedside work. The student is assisting the nurse who is preparing the medication of the patient with NG Tube. The student then asks to the nurse about the most suitable form of medication that can be administered through NG tube. Select the best response made by the nurse: a. Elixir b. Enteric coated c. Sustained release d. Sublingual The dietician recommended Ensure plus feed for the patient admitted in CCU (Critical care unit) to be started through Gravity bag. The amount to be given for a period of 4 hours is 250 mL. How many drops per minute the nurse will the set the flow rate of gravity bag? a. 20 drops/min b. 21 drops/min c. 28 drops/min d. 30 drops/min The gravity enteral feeding bag set which is used to provide continuous feeding should be discarded after? a. 24 hours b. 36 hours c. 48 hours d. 72 hours A clinical instructor is providing bedside teaching to the 2nd year BSc nursing students about the whoosh test on a patient with NG tube. Select the most appropriate statement related to the test? a. It is used to assess the correct placement of NG tube b. The examiner will place the diaphragm of the stethoscope over the epigastric region of abdomen to listen to the bubbling air sound. c. The air is injected with the help of syringe through the NG tube while simultaneously auscultating, a whoosh sound is heard which indicates the tube is in stomach. d. All of the above. The nursing intern has provided the bolus NG tube feeding with the help of 60 mL syringe to the conscious bedridden patient. Which of the following action by the nurse is recommended to prevent regurgitation after NG tube feeding? a. Place the patient in left lateral position for 1 hour after feeding b. Place the patient in fowlers position for 1–2 hours after feeding c. Place the patient in fowler’s position for 30–60 minutes after feeding d. Place the patient in supine position after NG tube feeding. A nurse is checking the nasogastric tube position of a client receiving a long-term therapy of Omeprazole by aspirating the stomach contents to check for the PH level. The nurse proves that correct tube placement if the PH level is? a. 7.75. b. 7.5. c. 6.5. d. 5.5 Before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 100ml. What is the appropriate action for the nurse to take? a. Discard the residual amount. b. Hold the feeding and inform to physician c. Re-instill the aspirated amount and continue with administering the feeding. d. Discard the aspirated volume and give feeding Continuous type of feedings is administered over a __ hour period.? a. 4. b. 12. c. 24. d. 36 FON (Part 3) Sabina CVP CARE  Identify the PICC Line? A B D C Most preferred site for CVP insertion? a. Left internal jugular b. Right Internal jugular c. Subclavian d. Femoral Type of CVP Catheter Size of CVC CVC Lumen Median Lumen, 18 G Proximal lumen 18 G Distal Lumen 16 G CVP Line Dressing Option c correct answer The most common preventable complication associated with CVP insertion? a. Central Line infection b. Thrombosis of vein c. Pneumothorax d. Haemothorax What does the PICC stand for? a. Peripherally injected central catheter b. Peripherally inserted central catheter c. Placed inverted central catheter d. Precisely implanted central catheter How often should the gauze dressing be changed? a. Every 2 days b. Every 3 days c. Every 4 days d. Every day You are providing care to a patient with triple lumen CVP line, but the lumens are not in use. How often should the nurse flush the CVP line lumen? a. Every 2 hourly b. Every 12 hourly c. Every 24 hourly d. No need to flush the lumen if it is not in use. Select the correct statement from the following? a. PICC line is a tunneled line b. Hickman is a tunneled CVP line c. Tunneled catheter are placed under the skin d. Both b & c The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the? a. Phlebostatic axis b. Point of maximum impulse (PMI) c. Erb's point d. Tail of Sphence What change occurs in the CVP reading if the transducer placed too high? a. High reading b. Low reading c. No change occur in the reading d. Abnormal reading What is the recommended method of flushing a CVC? a. The catheter should be flushed with a syringe no bigger than 10 ml, using a pulsated push-pause positive pressure technique. b. The catheter should be flushed using a pulsated push-pause positive pressure technique, with a syringe no smaller than 10 ml. c. The catheter should be flushed with a syringe no smaller than 10 ml, using a smooth not stop technique. d. Use a 2 ml syringe as this will give a higher pressure. A man is admitted for treatment of heart failure. The physician orders an IV of 125 mL of normal saline per hour and central venous pressure (CVP) readings every 4 hours. Sixteen hours after admission, the client’s CVP reading is 3 cm/H2O. Which of the following evaluations of the client’s fluid status by the nurse would be MOST accurate? a. The client has received enough fluid b. The client’s fluid status remains unaltered c. The client needs more fluid d. None of the above Which lumen is used to administered hypertonic TPN Solution from triple lumen CVP line? a. Distal lumen b. Proximal lumen c. Median lumen d. Lateral lumen FON (Part 4) Sabina Patient weight LMA size Maximum cuff volume in ml 100 6 50 The patient should be placed in which position for easy insertion of ETT? a. Sniffing Position b. Supine Position c. Reverse Trendelenburg Position d. Semi fowlers Position Position of ETT Insertion Select the accurate method of confirming the correct placement of an ETT? a. Aspiration method b. Bilateral Auscultation of lung sound c. Colorimeter d. Capnography SIZE OF ETT 1. ETT Insertion is called: 2. ETT Removal is called: 3. ETT depth: 4. Bevel of ETT is on which side: 5. ETT is inserted from which side of oral cavity: 6. ETT size represented in which unit: 7. ETT Size estimation formula: 8. ETT Cuff pressure & Measuring Device: 9. ETT standard Size of proximal adapter: 10. Best method to confirm placement of ETT: 11. Most accurate method to confirm ETT Placement: 12. Patient Position while intubating: 13. Colorimetric CO2 detector device change colour from ----- to -----. SUCTIOING  Suctioning 1. Suctioning method (OPEN) 2. Suctioning method (closed) 3. Suction pressure Adult: Child: Infant: 4. Patient Position while suctioning ETT: 5. ETT Suctioning Time duration: 6. Pre-oxygenate the patient before suctioning: Site of suctioning SUCTIONING METHOD Position while suctioning The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when: 1. The secretions are thinned. 2. The client coughs. 3. There is minimal friction when the catheter is passed into the tracheostomy tube. 4. There is humidification for the respiratory tract. When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds? 1. 5 seconds. 2. 15 seconds. 3. 20 seconds. 4. 30 seconds. Before suctioning a client with a tracheostomy, which nursing action should the nurse perform first? 1. Clean the tracheostomy stoma with a sterile, cotton-tipped applicator. 2. Instill 5 mL of saline within the tracheostomy. 3. Administer 100% oxygen for 30 seconds. 4. Occlude the vent on the catheter for 15 seconds. The nurse is caring for a patient with respiratory failure with an artificial airway by endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of a. Administer ordered antibiotics as scheduled. b. Hyperoxygenate the patient before suctioning. c. Maintain the head of bed at a 30- to 45-degree angle. d. Suction the airway when coarse crackles are audible. Doctor order an ETT removal, while preparing the patient for this procedure which initial nursing action is most appropriate? a. Suction the endotracheal tube b. Deflate the cuff c. Turn the ventilator off d. None of the above An adult man has a ET tube in place. Which of the following actions is most appropriate for the nurse to take when suctioning the tube? 1. Use a sterile tube each time and suction for 30 seconds 2. Use sterile technique and turn the suction off as the catheter is introduced 3. Use clean technique and suction for 10 seconds 4. Discard the catheter at the end of every shift During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take? 1. Release the suction by opening the vent 2. Continue suctioning to remove the obstruction 3. Increase the pressure 4. Suction deeper Which nursing action is essential during tracheal suctioning? 1. Using a lubricant such as petroleum jelly 2. Administering 100% oxygen before and after suctioning 3. Making sure the suction catheter is open or on during insertion 4. Assisting the client to assume a supine position during suctioning While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take? 1. Suction deeper to pick up secretions 2. Gently withdraw suction tubing to allow suction or coughing out of mucus 3. Remove the suction as quickly as possible 4. Put the suction tube in and out several times to pick up secretions The nurse is preparing to suction a client with an endotracheal tube. After ventilating, which is the correct sequence of actions for the nurse to follow during suctioning? 1. Apply suction, insert a sterile catheter, and withdraw while rotating the catheter. 2. Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw while rotating the catheter. 3. Apply suction, insert a sterile catheter, and withdraw without rotating the catheter. 4. Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw without rotating the catheter. You are taking care of an adult patient who is on synchronized intermittent mandatory ventilation (SIMV) mode. To keep the airway patent, doctor recommended for the open suctioning procedure which is to be performed every 4-hourly. Before doing the procedure, you have checked the patient unit and the suction apparatus for proper functioning. What pressure will you set on the wall mounted suction apparatus for performing suction on this patient? a. 50-100 mmHg b. 100-150 mmHg c. 150-200 mmHg d. 250-300 mmHg To perform suctioning of an ET tube, one has to disconnect the patient’s ET tube from the mechanical ventilator, to avoid this disconnection which type of suction catheter will be used for an ET tube suctioning? a. Closed suction catheter b. Thumb pressure control suction catheter c. Plain suction catheter d. Fingertip pressure control suction catheter The nurse has inserted the thumb pressure control suction catheter into an ETT until she felt the resistance. After that she pulled back the suction catheter at 1-2 cm above the resistance in order to avoid which complications? a. Bradycardia b. Tachycardia c. Infection d. Hypotension FON (PART 5) Sabina BLOOD TRANSFUSION A client who had a total hip placement at 9 AM is receiving an autologous blood transfusion that was started at 11 AM. At the change of shift (3 PM), the day nurse reports that there is 50 mL of the unit of blood remaining to be infused. Which of the following is a priority action for the evening nurse? 1. Keep the blood transfusing at the same rate. 2. Increase the rate so it will infuse by 4 PM. 3. Discontinue the blood transfusion at the beginning of the shift. 4. Maintain the current rate and discontinue the blood transfusion at 5 PM The nurse is monitoring a client receiving a blood transfusion when the client develops a cough with shortness of breath. The client also has a headache and a racing heart. What should the nurse do first? 1. Slow the infusion rate. 2. Replace the blood with saline. 3. Administer an antihistamine. 4. Place the client flat with the feet elevated. A client who is receiving a blood transfusion begins to have difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications? 1. Anaphylactic reaction. 2. Circulatory overload. 3. Sepsis. 4. Acute hemolytic reaction The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Remove the IV catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion. A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last? 1. Notify the attending physician and blood bank. 2. Complete the appropriate Transfusion Reaction Form(s). 3. Stop the transfusion. 4. Keep the IV open with normal saline infusion. When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply. 1. Send freshly collected urine samples to the laboratory. 2. Return the remainder of the blood component unit to the blood bank. 3. Return the intravenous administration set to the blood bank. 4. All of the above A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next? 1. Administer prescribed antihistamine and aspirin. 2. Collect blood and urine samples and send to the lab. 3. Administer prescribed diuretics. 4. Administer prescribed vasopressors. A client with early acute renal failure has anemia, tachycardia, hypotension, and shortness of breath. The physician has prescribed 2 units of packed red blood cells (RBCs). Prior to initiating the blood transfusion the nurse should determine if: (Select all that apply.) 1. There is an IV access with the appropriate tubing and normal saline as the priming solution. 2. There is a signed informed consent for transfusion therapy. 3. Blood typing and cross-matching are documented in the medical record. 4. The vital signs have been taken and documented in accordance with facility policy and procedure. 5. There is the second unit of blood in the medication room. 6. The client has an identification band on wrist. When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for which of the following? 1. Hypertension. 2. Diaphoresis. 3. Polyuria. 4. Warm skin. You have started blood transfusion to your assigned patient and within 15 minutes of transfusion the patient started complaining of itching, chills, and a headache. Which action by the nurse is most appropriate in this situation? a. Stop the transfusion b. Notify the physician c. Decrease the rate of the transfusion d. Reassure the patient that this is normal and will resolve in 30 minutes. What solution is considered as compatible with red blood cells? a. Normal Saline 0.9% b. Dextrose Solutions c. RL Solution d. Both a & b You have received a RTA case with severe blood loss. Attending doctor prescribed with multiple transfusion of blood. Which most essential piece of equipment should the burse use to prevent the risk of cardiac dysrhythmias? a. Cardiac monitor b. Blood warmer c. ECG machine d. Infusion pump You have started a blood transfusion to your patient admitted with hb = 8g/dl. How long the nurse should remain at the patient bedside to check for blood transfusion reaction? a. 15 minutes b. 30 minutes c. 45 minutes d. 60 minutes Nurse Rick is administering a 2 unit packed RBC’s on a client with a low hemoglobin. The nurse will prepare which of the following in order to transfuse the blood? a. Micro fusion set b. Polyvol Pro Burette Set c. Photofusion set d. Tubing with an in-line filter Polyvol Pro Burette Set Photofusion set Within 15 minutes of PRBCs transfusion your assigned patient started complaining of nausea and vomiting. Patient BP is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s temperature is 100.5°F orally from a baseline of 99.5°F orally. From this the nurse understands that the patient may be experiencing which of the following? a. Circulatory overload b. Delayed transfusion reaction c. Hypocalcemia d. Septicemia You are preparing the blood transfusion tray as per the doctor order of transfusion of one unit of Packed RBCs to the patient transferred from emergency department. Before starting the transfusion you found that the patient’s temperature is 100.9 °F. Which action should the nurse take? a. Give an antipyretic and begin the transfusion. b. Normal reading, start the transfusion c. Hold the blood transfusion and inform the attending doctor d. Administer an antihistamine and begin the transfusion. The patient with O+ blood group is in need of an emergency blood transfusion but the blood bank does not have any O+ blood available. Which potential unit of blood could be given to the patient? a. O –ve unit b. A+ unit c. B+ unit d. AB + A nursing intern is posted in post-operative ICU where she is assisting to bedside registered nurse who is administering PRBCs transfusion to her patient. The nursing intern asks why it is recommended to complete the blood transfusion of a unit of blood in less than four (4) hours. Which among the following option should the registered nurse select to answer this question? a. The blood will coagulate if left out of the refrigerator for >four (4) hours. b. The blood has the potential for bacterial growth if allowed to infuse longer. c. The blood components begin to break down after four (4) hours. d. All of the above The nurse is caring for a 50-year-old patient with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action? a. Slow the transfusion. b. Document the finding as the only action. c. Stop the blood transfusion and turn on the normal saline. d. Assess the client's pupils." Reenu registered nurse receives a doctor’s order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which of the following procedures is most appropriate for infusing this blood product? a. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. b. Infuse the fresh frozen plasma for 4 hours. c. Add normal saline and then infused d. None of the above A nurse received a unit of blood from the blood bank and notes the presence of gas bubbles in the bag. Which action should the nurse take in this situation? a. Return the bag to the blood bank. b. Infuse the blood using the filter tubing. c. Add 10ml of NS to the bag. d. Agitate the bag to mix contents gently. The client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? a. Increased hematocrit level b. Increased hemoglobin level c. Decline of elevated temperature to normal d. Decreased oozing of blood from puncture sites and gums A patient needs 2 units of packed red blood cells. The patient is typed and cross matched. The patient has A+ blood. As the nurse you know the patient can receive what type of blood? Select all that apply:* A. A- B. O- C. O+ D. A+ E. AB- F. AB+ G. B+ You’re educating a group of outpatients about ABO blood typing and compatibility. Which statement is INCORRECT? a. A person with B- blood can donate to people with either B- or AB- blood. b. A person with B- blood can receive blood from donors with O- and B- blood. c. A person with O- blood can donate to every blood type regardless of the RH factor. d. A person with AB+ blood can only donate to other people with either AB+ or AB- blood. The rise in hemoglobin levels after one unit of whole blood transfusion is a. 55 g% b. 1g% c. 5 g% d. 2 g% In massive transfusion of blood, citrate toxicity is primarily due to a. Hemolysis b. Coagulopathy c. DIC d. Direct binding to calcium A most common blood transfusion reaction is: a. FNHTR b. Hemolysis c. Transmission of infections d. Electrolyte imbalances How long can blood be stored with CPDA-1 a. 21 days b. 28 days c. 35 days d. 42 days  Articles Requiredc Vacutainer Needle Vacutainer Needle Holder DON'Ts of Specimen Collection Do not pre-label specimen containers prior to collection. Do not leave the patient until all specimen containers are labeled. FON (Part 6) Ms. Sabina TRACHEOSTOMY CARE  Tracheostomy Tube Inner cannula Cuff inflation Cuff Pilot line balloon Obturator Flange Velcro Strap A client has just arrived in the ICU following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed B. Clean the tracheostomy inner cannula and stoma C. Listen to lung sounds D. Change the tracheostomy dressing as needed Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. None of the above Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives. Which of the following is not a definitive airway? a. Tracheostomy b. Endotracheal tube c. Nasotracheal tube d. Laryngeal mask airway What should the tracheostomy stoma site be cleaned with? a. Povidone iodine b. Chlorhexidine gluconate c. 0.9% normal saline solution d. Antimicrobial handwash A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to: 1. Call for emergency assistance. 2. Attempt reinsertion of tracheostomy tube. 3. Position the client in semi-Fowler's position with the neck hyperextended. 4. Insert the obturator into the stoma to reestablish the airway. The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure? 1. Remove the inner cannula every 2 hours for cleaning. 2. Secure the tracheostomy ties with a square knot. 3. Cut gauze piece and place under the neck plate to protect the skin. 4. Suction the inner cannula on completion of the procedure The nurse is making rounds and observes the client who had a tracheostomy tube inserted 2 days ago (see figure below). The nursing policy manual recommends use of the gauze pad. The nurse should: 1. Make sure the gauze pad is dry and the client is in a comfortable position. 2. Ask the nursing assistant to tie the tracheostomy tube ties in the back of the client's neck. 3. Reposition the gauze pad around the stoma with the open end downward. 4. Ask a registered nurse to change the ties and position another gauze pad around the stoma. Complications associated with having a tracheostomy tube include: 1. Decreased cardiac output. 2. Damage to the laryngeal nerve. 3. Pneumothorax. 4. Acute respiratory distress syndrome (ARDS). CHEST TUBE DRAINAGE A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first? 1. Notify the physician 2. Give the client whatever medication was ordered to decrease anxiety 3. Check the chest tube to make sure it is not obstructed 4. Turn up the oxygen liter flow While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. Which of the following should be the nurse's first action? 1. Lower the head of the bed and call the physician. 2. Prepare an aspiration tray. 3. Mark the area with a skin pencil at the outer periphery of the crackling. 4. Turn off the suction of the chest drainage system.A client has a chest tube attached to a water-seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine that: 1. The lung has fully expanded. 2. The lung has collapsed. 3. The chest tube is in the pleural space. 4. The mediastinal space has decreased. The nurse is preparing to assist with the removal of a chest tube. Which of the following is appropriate at the site from which the chest tube is removed? 1. Adhesive strip (Steri-strips). 2. Petroleum gauze. 3. 4 × 4 gauze with antibiotic ointment. 4. No dressing is necessary A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system. Which of the following should be readily available at the bedside of a client with a chest tube in place? 1. A tracheostomy tray. 2. Another sterile chest tube. 3. A bottle of sterile water. 4. A spirometer A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Respiratory rate greater than 16 breaths/min. 2. Continuous bubbling in the water-seal chamber. 3. Fluid in the chest tube. 4. Fluctuation of fluid in the water-seal chamber An adult has a chest drainage system. 2 hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling? 1. The client’s lungs have re-expanded. 2. There is an obstruction in the tubing coming from the client. 3. There is a mechanical problem in the pump. 4. Air is leaking into the drainage apparatus. Identify the marked area of the given image? Nurse Rose has assigned to provide care to her patient who is with a chest tube catheter. On assessment of the drainage system, the nurse has observed that there is gentle bubbling in the water seal chamber when the patient breaths. Which among the following is the primary nursing action to be applied by the nurse Rose? a. Inform to the doctor immediately as it is considered as an abnormal finding. b. Check the drainage system for any air leakage c. Continue to monitor as this is considered as a normal finding d. Check the drainage system for any tube kink or obstruction. While taking the nursing round you have noticed that one of the patient’s chest tube drainage system has disconnected from the chest tube catheter and fallen onto the floor. While the chest tube catheter is secured with sutures and hanging in the air. What is your priority nursing action? a. Inform to the team leader immediately b. Insert the chest tube catheter tubing 1 inch into a bottle of sterile water and obtain a new system. c. Clamp the chest tube catheter and inform to the doctor d. Remove the chest tube catheter from the insertion site to reduce the risk of infection. Your senior nurse instructs you to prime the chest tube drain before connecting to the chest tube catheter. Which among the following statements are related to the priming of a chest tube drainage system? a. Fill the drainage bag with the sterile water up to the prime level before connecting to the chest tube catheter b. Use 20mL of sterile water to prime as indicated on the drainage system. c. Make sure the tip of the distal end of the drainage tube is submerged in 2cm of H2O. d. All the above Identify the highlighted part of a given below image? a. Heimlich valve b. Flow regulator c. Sampling extractor d. Corrugated drain sheet The nurse is assisting the doctor in the removal of Chest tube drain. The nurse should instruct the patient to follow which action while removal of chest tube? a. Take a deep breath and hold b. Purse lip exercise c. Take a deep breath and bear down d. Both a & c The post-operative nurse receives a patient with chest tube from the Operation Theatre. Two hours later when the nurse checks the chest tube drainage collection chamber it was completely empty. Which action the nurse should perform in such situation? a. Clamp the chest tube b. Milking of chest tube c. Turn the patient from side to side d. Keep the chest tube drainage on the patient’s bed The nurse will set the suction chamber of underwater seal drainage system at what pressure in adult patient with chest tube? a. -20 cm H20 b. -5 cm H20 c. -2 cm H20 d. 0 cm H20 A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? a. The water in the chamber will increase during inspiration and decrease during expiration. b. There will be continuous bubbling noted in the chamber. c. The water in the chamber will decrease during inspiration and increase during expiration. d. The water in the chamber will not move. While helping a patient with a chest tube reposition in the bed, the chest tube catheter becomes dislodged from the insertion site What is your immediate nursing intervention? a. Stay with the patient and monitor their vital signs while another nurse notifies the physician. b. Place a sterile dressing over the site and tape it on three sides and notify the physician. c. Attempt to re-insert the tube. d. Keep the site open to air and notify the physician. FON (Part 7) Sabina OXYGEN THERAPY Color of the shoulder of Oxygen Cylinder should be: a. White b. Black c. Blue d. Yellow Identify the image? A) B) After the consultant round the attending doctor change the patient current oxygen therapy and order to start oxygen with high flow oxygen device. The nurse will select which of the following oxygen devices as per the doctor’s order? a. Non Rebreathing Mask b. Nasal Prong c. Simple face mask d. Venturi Mask In emergency unit you have received a male trauma victim and while monitoring the vital signs the victim’s arterial oxygen saturation is 88%. The doctor order to start the oxygen therapy. Which oxygen device should be best suited for this patient? a. Simple mask b. Non-rebreather mask c. N-95 Mask d. Nasal cannula The nurse is to start oxygen therapy via nasal cannula. Which action is correct? 1. Set the oxygen at 12 L/min. 2. Lubricate the cannula with petroleum jelly before inserting. 3. Give 100% oxygen by mask before inserting the cannula. 4. Insert the cannula 1 cm into the nostrils. Which of the following oxygen device the nurse will use in order to deliver high concentration of oxygen? a. Partial rebreather Mask b. Non-rebreather mask c. Venturi mask d. Nasal prongs Highest concentration of oxygen is delivered through: a. Nasal cannula b. Venturi mask c. Bag and mask d. Mask with reservoir The red venture valve is used to deliver ----------FiO2? a. 24% b. 35% c. 40% d. 60% In case of COPD which of the following oxygen device is used? a. Venturi mask b. Simple face mask c. NRM d. Nasal prongs IV CANNULATION You are taking handover of your assigned patient, at the patient’s bedside you noticed that the patient's IV site is cool, pale, and swollen, and the solution is not infusing. Which of the following complication you will document in your handover report? a. Phlebitis b. Infection c. Infiltration d. Extravasation Rohit, morning shift Cardiac ICU nurse receiving a transfer report of a patient with dehydration and pneumonia from emergency department. After receiving the patient from the emergency department, the nurse notices that his I.V. infusion has infiltrated. Which of the following is the best initial response by the nurse? a. Stop the infusion, remove the I.V. b. Apply a cool compress to the site. c. Apply moist heat to the site. d. Massage the IV site. You are inserting an IV line into a client's vein. After the initial prick, you should continue to advance the catheter if: a. Immediately after pricking advance the cannula b. The client does not complain of discomfort c. Blood return shows in the backflash chamber of the catheter. d.None Which among the following intravenous (IV) cannula is correctly matched according to their gauze size and colour? a. 18-gauge IV Cannula = Pink b.26-gauge IV Cannula= Purple c. 16-gauge IV Cannula= Green d.14-gauge IV cannula = Grey  THANK YOU 👍 CLICK HERE- https://t.me/Clinical_Nursing