Nursing Skills 2 Exam Study Guide PDF October 2024

Nursing Skills 2 Exam Study Guide October 2024 Week 1 - Chapter 2 Transitions in Care - Discharge planning begins at admission! ➔ Patients and families need to be involved - Admission assessments include age, gender, ethnicity, culture, and religion - Nurse-to-nurse hand...

Nursing Skills 2 Exam Study Guide October 2024 Week 1 - Chapter 2 Transitions in Care - Discharge planning begins at admission! ➔ Patients and families need to be involved - Admission assessments include age, gender, ethnicity, culture, and religion - Nurse-to-nurse handoff can create information gaps, omissions, and errors - Medication reconciliation helps avoid errors Common admission procedures - Placement of patient - Patients rights - Assessments - Development of PCC - Identification - Orientation - Testing + screening - Payment source Patient’s Rights - Informed consent - Advance care plan - Confidentiality + privacy - Refuse treatment - End-of-life care - Organ procurement - Substitute decision maker - Second opinion - Pain + symptom management - Request assisted death - Advance directives - Advance directives: document that describes which medical treatment or non-medical a patient chooses for future medical care Nurse Responsibilities - Complete a comprehensive nursing assessment - Review any existing advance directives  - Ensure continuity of care - Coordinate initial admission - Kearn fears + concerns - Nursing plan of care - Note level of fatigue - Priority care needs + safety risks What information must be provided during admission? - General consent - Patient’s rights - Advance directives What are some nursing diagnoses with admission? - Acute pain - Anxiety - Insufficient knowledge about hospital procedures - Fear What age - appropriate behavior related to separation anxiety will a child exhibit? - Difficulty sleeping Goals - Transitioning - Ensure continuity of care - Collaborate - Communicate Discharge Planning - Early and comprehensive planning = smooth - Effective discharge reduces transmission - Stages: ➔ Acute care ➔ Transition care ➔ Continuing care - Complete a discharge summary Nursing Diagnosis for Discharge - Anxiety - Relocation stress syndrome - Caregiver role strain - Interrupted family processes Chapter 2 Practice Questions - Bolded are correct 1. Which of the following is part of the standard admission procedure? - Orientation to policies  - Assessment of patient health care needs - Patients rights and elements of advance directives - Preliminary testing and screening - Development plan of care 2. Patients who fall typically are those who: - Have chronic illness - Take analgesics - Take one medication - Have unsteady gait 3. Two essential components of successful transitions to LTC facility - Medication lists - Advance directives - Family contact - Dietary preferences Week 2 - Chapter 37 + 38 Perioperative Care Is it within an LPNs scope of practice to care for a fresh post-op client? - No, fresh post- op must go to PACU first - Only when reach stability + consciousness Pre-op Care Phases - Pre-op: before surgery - Intraoperative: during surgery - Post-op: after surgery Categories or Surgeries - Emergency - Urgent - Elective - Major Surgeries: general anesthesia - in-patient - Minor Surgeries: often outpatient, local anesthesia Post-Op Exercises - Diaphragm breathing - Coughing - Turning - Leg exercises Pre-Op Considerations - What to know: ➔ Previous surgeries ➔ Extent of surgery  - What to check: ➔ Informed consent ➔ All required documents ➔ Patient prep Pre-Op Actions - Pain relief - Restrict activity - Document Reporting Protocols - Lack of signed consent form - Failed to maintain NPO - Cultural practices and beliefs Chapter 37 + 38 Practice Questions 1. During the initial assessment of a patient in the postanaesthesia care unit (PACU), the nurse notes bleeding that is beginning to seep through the top layer of the dressing. What actions should the nurse take immediately? Assess the patient’s vital signs and notify the surgeon. Mark the drainage with a felt-tipped marker and continue to monitor. Lift the dressing to assess bleeding, and raise the patient’s legs. Circle the drainage on the dressing, and check it again within 10 minutes 2. A patient underwent a short procedure under procedural sedation and is in the recovery area. What action by the nurse would be expected to best promote the patient’s respiratory function? Positioning the patient with the head elevated with slight neck flexion Placing the patient on the side with head elevated and arms over the chest Positioning the patient on the side with neck slightly extended Placing the patient flat either supine or on the side 3. A patient is unable to perform lower leg exercises postoperatively because of a spinal cord injury that occurred many years ago. Nursing care would be appropriate if the nurse were observed performing which activity? Encouraging the patient to perform active range of motion of the feet and knees Placing a footboard to give the patient something to press his feet against Providing passive range of motion to the lower extremities every 2 hours Wrapping 10-cm (4-inch) elastic bandages on both legs from ankle to calf 4. The patient asks the nurse why she has to stop smoking at least a month before surgery. Which response by the nurse would be most accurate?  “Withdrawal of nicotine gives the physician a better assessment of your true pain level.” “If any respiratory problems occur, your physician will be able to detect them immediately.” “The use of tobacco products prevents the blood from clotting as effectively as usual.” “The use of nicotine decreases wound healing and increases the chance of infection.” 5. The nurse in the postanaesthesia care unit (PACU) is caring for several patients. Which patient needs to be watched most carefully for postoperative thrombus formation? A 45-year-old woman with poor pedal pulses who takes oral contraceptives A 68-year-old man who is slightly hypertensive and anemic A 38-year-old man who just had his appendix removed A 56-year-old overweight man who plays golf twice every week Week 3 - Chapter 39 + 40 Wound Care and Sterile Normal Process For Wound Healing - Healing Intentions ➔ Primary intention - surgical incisions ➔ Secondary intention - pressure ulcers - Process: hemostasis, inflammation, proliferation, maturation T- Tissues Management I- Inflammation + Infection M- Moisture Balance E- Edge of wound Wound Classification - Stage of skin integrity - Severity - Cleanliness - Descriptive qualities Wound Drainage Characteristics - Color - Consistency - Amount - Odor - Types of Drainage: ➔ Sanguineous ➔ Serosanguineous ➔ Purulent Dressing + Wound Care  - When to change a dressing: ➔ Scheduled change ➔ When visibly soiled or wet ➔ After a shower Types of Dressings - Primary dressings: contact the wound - Secondary dressings: cover primary dressing Wound Complications - Hemorrhage - Infection - Dehiscence - wound edges separate - Evisceration - internal organs protrude - Fistulas - Sinuses Chapter 39 + 40 Practice Questions 1. The nurse is turning a patient when she notices an area with nonblanchable redness over the patient’s coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed a stage I pressure injury. a stage II pressure injury. an unstageable pressure injury. deep tissue injury. 2. In a patient with a stage II pressure injury, the nurse describes the wound as superficial blistering. non blanchable redness. loss of skin without bone exposure. loss of skin with exposed muscle. 3. The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure injury? The patient who is bedridden but who turns himself randomly The patient whose Braden Scale score is 8 The patient who can ambulate to the bathroom independently The patient whose Braden Scale score is 18 4. Aggressive prevention measures should be implemented for a patient in the general population with a pressure injury risk on the Braden Scale of less than or equal to 16. 18.  20. 24. 5. In a long-term care facility, how often should the nurse reassess a patient for risk of a pressure injury? Every 1 to 2 days Every time the nurse sees the patient Weekly for the first few weeks of stay Monthly for the first 4 months of stay 6. A patient developed a 2-cm stage 1 pressure injury over the sacrum. A transparent dressing has been in place for 2 days. The nurse on the evening shift notices that the skin under the dressing appears broken. The patient complains of tenderness when the nurse palpates the skin. The nurse also notices drainage under the transparent film. What action should the nurse take in this situation? Remove the dressing and obtain an order for a wound culture. Record observations and keep the dressing in place. Increase the frequency of changing the transparent dressing. Consider irrigating the wound. 7. A patient was originally in the critical care unit and has been moved out to the general surgery unit. The patient is obese and has a 20-cm abdominal incision. The nurse makes rounds and begins to check the patient’s dressing when the patient tells the nurse, “I think I felt something just give way in my belly.” The nurse removes the gauze dressing over the incision and sees that the wound has serosanguineous drainage. What should be the nurse’s next step? Notify the patient’s health care provider. Check the patient’s blood pressure and heart rate. Cover the wound with gauze moistened in sterile saline. Instruct the patient to lie on the right side. 8. A patient with a large surgical wound that is healing by secondary intention has an order for the wound to be packed with gauze that has been moistened in saline. Which of the following steps in packing a wound is incorrect? Pack the wound gently. Cover moist gauze packing with dry sterile gauze. Avoid placing gauze in the sinus tract or an undermined area of the wound. In the case of a deep wound, wear sterile gloves. 9. Normal wound healing requires a physiological wound environment that includes which of the following?  Control of bacterial burden A lack of moisture An acidic environment Tissue eschar 10. A patient underwent a cardiac catheterization in the area of the right groin and has been taken to the recovery room. The patient has a history of being on warfarin. The registered nurse assigned to the patient identifies bright red blood oozing from the patient’s groin area. Place in order the steps the nurse should take to correctly apply a pressure bandage. 1. Seek assistance from a second nurse. 2. Apply manual pressure to the groin area immediately. 3. Identify the source of bleeding. 4. Second nurse unwraps a roller bandage and prepares lengths of adhesive tape as the first nurse applies pressure. 5. Place adhesive strips 7 to 10 cm beyond the width of gauze dressing with even pressure on both sides of the second nurse’s fingers close to the central bleeding source. 6. Rapidly cover the bleeding area with multiple thicknesses of gauze compresses. 1, 2, 3, 4, 6, 5 2, 1, 3, 4, 6, 5 4, 1, 2, 3, 5, 6 3, 2, 1, 4, 5, 6 Quiz 1 Test Questions (Incorrect ones) 1. Your client, Ruth, has had a right total hip replacement and is being readied for discharge. To ensure safe nursing care prior to surgery. Which intervention is appropriate? Assist her with brushing her teeth and allow her to swallow the water Allow the client to have ice chips by mouth Keeping her NPO for a minimum of 15 hours Administer specifically ordered medications with small sips of water 2. During admission of a patient, the nurse notes that the patient speaks another language and does not understand English. What should the nurse do to facilitate communication? Use hand gestures to explain Work with the family to gather information Request and wait for a medical interpreter Use simple phrases to complete the admission 3. When providing care for a postoperative patient, it is important for the nurse to include which postoperative exercise? Completing individual leg exercises 30 times Completing leg exercises once per shift  Performing exercises with affected and unaffected extremities Turning every 4 hours 4. After receiving pre-op medication, the client needs to void. What should the nurse do? Notify the physician Seek an order to mobilize the client Provide the client with a bedpan or urinal Walk the client to the bathroom 5. The nurse explains to the patient that the incentive spirometer is used to promote: Production of mucus Decrease use of pain medication Lung expansion Incisional healing 6. At what point would the client sign the surgical consent form? At the completion of the physical exam After receiving pre-op medication During admission with the admitting clerk After the surgeon explains the procedure 7. During a pre-op assessment why would the nurse ask the client about his or her response to previous surgeries? To determine the amount of pain meds the client will need To identify anatomic and physiologic alterations that may affect care To predict the patient’s possible responses to anesthetic To help estimate the length of hospital stay 8. When is healing by primary intention expected? When connective tissue development is evident When the edges of a clean incision remain close together When a surgical wound is left open for 3 to 5 days When wound edges are open 9. The primary reason for wound irrigation is to: Facilitate healing by primary intention Remove debris from the wound Increase scar formation Decrease circulation to the wound 10. When exposed to wound drainage, these highly absorbent fibrous dressings turn to gel, which is easily removed from a wound without causing tissue trauma. Gauze Alginate and hydrofiber dressings Hydrogel dressings Hydrocolloids 11. Which of the following factors can be modified by the client to help support adequate oxygenation at the tissue level? Underlying cardiopulmonary conditions Hemoglobin levels Smoking Age 12. The patient has a large, deep wound on the sacral region. The nurse correctly packs the wound by: Leaving saline-soaked folded gauze squares in place  Filling two-thirds of the wound cavity Putting the dressing on very tightly Fluffing the packing and filling to the upper edge of the wound 13. The nurse is changing surgical dressing and is cleansing the wound. She knows that: The incision line should be cleansed last She should work in a circular motion around the incision line She should use hydrogen peroxide to cleanse the incision She should start at one end of the incision line and swab the entire length 14. The nurse is changing a film dressing over a wound that is showing a large amount of drainage. How should the nurse proceed? Keep the wound open to air Apply a film dressing after cleansing the area Choose another type of dressing for this wound Apply a fil dressing after culturing the wound 15. A _____________ dressing comes in direct contact with the wound bed Tertiary Multi-layer Secondary Primary Week 5 - Chapter 32, 33, 41 Hot and Cold, Enteral and Parenteral Feeding Enteral Nutrition (Chapter 32) - Definition: ➔ Enteral Nutrition: Delivery of nutritional formulas through a tube inserted into the gastrointestinal (GI) tract. - Indications: ➔ Required for patients with limited ability to chew or swallow. - Goals: ➔ Maintain normal digestion and absorption of nutrients. - Tube Types: ➔ Nasogastric (NG) Tube: Delivers substances to the stomach or removes gastric contents. ➔ Jejunostomy (J-tube): Delivers feeds directly to the jejunum in the small intestine. ➔ Gastrostomy (G-tube, PEG): Provides access for medications, fluids, and nutritional support. Managing Enteral Nutrition: 1. Initiation Procedure: ○ Measure tube length. ○ Lubricate the tip and insert the tube through the nose or mouth, advancing to the stomach. ○ Secure the tube and aspirate gastric content to confirm placement. ○ Assess abdomen for bowel sounds and signs of distress.  2. Feeding Types: ○ Continuous Feedings: Nutritional infusion at a constant rate. ○ Intermittent Nutrition: Bolus feeding over 15-40 minutes multiple times daily. 3. Complications: ○ Aspiration and respiratory distress. ○ Tube dislodgement. ○ Abdominal pain, cramping, or diarrhea. ○ Nutritional inadequacy. 4. Safety Factors: ○ Confirm correct tube placement. ○ Monitor feeding tolerance. ○ Flush the tube before and after feeding and medications. LPN Role with NG Tubes: Insertion: Not permitted. Removal: Allowed. Assessment, Administration, Monitoring, Maintenance: Within scope. Administering Enteral Feeds: 1. Before Feeding: ○ Assess tube length and confirm placement. 2. During Feeding: ○ Monitor for misplacement signs (e.g., coughing, dyspnea). 3. After Feeding: ○ Use pH paper to check gastric content acidity; confirm placement with X-ray if necessary. NG Tube Removal Procedure: 1. Position patient in high Fowler's or at 30 degrees. 2. Apply clean gloves and place a towel on the patient's chest. 3. Remove tape and pinch the tube while instructing the patient to take a deep breath and hold it. 4. Carefully remove the tube and dispose of it appropriately. Parenteral Nutrition (Chapter 33) - Definition: ➔ Parenteral Nutrition (PN): Nutritional support administered intravenously for patients unable to receive nutrients via the digestive system. - Indications: ➔ Used when the digestive system is non-functional or requires rest. - Central vs. Peripheral PN:  ➔ Central PN: Delivered via a large central vein. ➔ Peripheral PN (PPN): Delivered via a peripheral vein; less hypertonic. - Goals of TPN: ➔ Correct or prevent malnutrition. - Potential Complications: ➔ Dehydration and electrolyte imbalances. ➔ Thrombosis, hyperglycemia, hypoglycemia. ➔ Infection and liver failure. LPN Role in Parenteral Nutrition: Administer fluids, medications, TPN, and blood products through central lines. May access lines for blood draws and emergency medications. Hot and Cold Therapy (Chapter 41) - Therapeutic Uses: ➔ Heat Therapy: For muscle relaxation, improved circulation, and decreased stiffness (e.g., stomach cramps, leg cramps). ➔ Cold Therapy: For reducing swelling and pain (e.g., sprains). - Differences Between Heat and Cold: ➔ Cold Therapy Effects: Reduces swelling, nerve activity, and pain. ➔ Heat Therapy Effects: Increases temperature, circulation, muscle relaxation, and decreases stiffness. - Moist vs. Dry Heat: ➔ Moist Heat: Includes hot compresses and sitz baths; penetrates faster and deeper than dry heat. - Application Products: ➔ Heat Products: Warm water, hot water bottles, heating pads. ➔ Cold Products: Ice packs, coolant sprays, ice massage. - Application Steps: ➔ Cold Therapy: Apply to acute injuries for 15-20 minutes, wrapped in cloth to protect the skin. Allow recovery time before reapplying. ➔ Heat Therapy: Ensure skin is dry, use a towel for insulation, and assess skin after a few minutes. - Safety Considerations: ➔ Heat Risks: Skin burns, increased swelling, cardiovascular strain. ➔ Cold Risks: Heart issues, apply for limited durations. Practices Questions for 32, 33, and 41 1. Which of the following skills can be delegated to unregulated care providers (UCPs) in caring for patients receiving enteral nutrition? Providing pH testing of fluid withdrawn through a feeding tube Providing oral hygiene to patients with nasogastric tubes  Irrigating a feeding tube to maintain patency Inserting a feeding tube 2. Which of the following is the most serious complication of tube feeding? Diarrhea Aspiration pneumonia Nausea Electrolyte imbalance 3. Which of the following measures is most effective in preventing feeding tube occlusion? Diluting formula to half strength Irrigating the tube with water every 4 hours Substituting cranberry juice for water as flush solution Mixing medications with formula before administration 4. Adherence to which of the following measures aims to improve safety in administration of enteral feedings? Use of pumps designated for tube feedings, not intravenous fluids Using only Luer-Lok syringes or extension sets on enteral systems Auscultating the epigastric area while instilling air through the tube Encouraging patients and caregivers to reconnect tubing that has separated 5. Place in the correct order the steps for administering enteral nutrition. 1. Connect feeding administration set to feeding tube. 2. Verify correct enteral product and check expiration date. 3. Fill the feeding container with formula, or attach tubing to the ready to hang container. 4. Perform hand hygiene. 5. Activate pump or open roller clamp. 6. Verify tube placement. 1, 2, 3, 4, 5, 6 2, 1, 3, 4, 6, 5 4, 2, 3, 6, 1, 5 4, 3, 5, 6, 2, 1 6. When reviewing the documentation of patients on the unit, a nurse determines that one of the patients is at higher risk for injury from a local heat application to an extremity. Which condition poses this risk? Arthritis Renal calculi Pulmonary disease Peripheral neuropathy  7. The nurse is removing a heating pad and notices that the skin beneath the pad is pink and warm to touch. How should the nurse respond? Keep the pad in place the next time by pinning it with a safety pin. Position the patient next time so that the patient is lying directly on the pad. Document the findings. Put the pad back on for an additional 20 to 30 minutes. 8. For which patient should the nurse consider an application of cold? Menstrual cramping Infected wound Fractured ankle Degenerative joint disease 9. The use of cold (cryotherapy) to treat certain injuries is beneficial because of which of the following effects? Relief of pain Decreased vasoconstriction Increased nerve conduction Increased vasodilation 10. Advantages of moist heat over dry heat include which of the following manifestations? Reduces drying of skin Encourages wound exudate Does not cause skin maceration Penetrates superficially into tissue layers Week 6 - Chapter - 34, 35, 36 Urinary, Bowel, and Ostomy Care Characteristics of Urine and Factors Influencing Urination - Normal and Abnormal Urine Characteristics ➔ Normal Urine: ○ Appearance: Clear ○ Color: Pale yellow ○ pH: Slightly acidic ○ Composition: No protein, glucose, blood, or bacteria ➔ Abnormal Urine: ○ May contain blood, protein, glucose, or bacteria. ○ Can appear cloudy or have a strong odor.  - Factors Influencing Urination ➔ Age: Changes in kidney function and bladder capacity. ➔ Fluid Intake: Directly affects urine volume and concentration. ➔ Medications: Certain drugs can alter urine characteristics. ➔ Muscle Tone: Weak pelvic floor muscles can affect bladder control. ➔ Psychological Factors: Anxiety or stress can influence urination patterns. ➔ Surgical Procedures: May impact urinary function temporarily or permanently. ➔ Medical Conditions: Diabetes, urinary tract infections (UTIs), and others can affect urination. Principles for Practice in Urinary Elimination - Adequate Oral Intake: Essential for bladder health; average adult output is 1-2 liters in 24 hours. - Signs of Dehydration and Fluid Overload: Important to recognize to maintain fluid balance. - Assessment Methods: ○ Evaluate serum electrolytes. ○ Weigh the patient. ○ Monitor fluid status. - Person-Centered Care: ○ Understand patient values and preferences. ○ Adapt procedures to respect dignity and cultural beliefs. Urinary Catheterization and Catheter Types - Types of Urinary Catheters ➔ Intermittent Catheters: ○ Urethral (Foley, straight) and condom catheters. ○ Inserted as needed for temporary use. ○ Indwelling Catheters: ○ Urethral (Foley) and suprapubic catheters. ○ Remain in place for continuous drainage. - Reasons for Catheterization ➔ Incontinence Types: Stress, urge, and overflow. ➔ Other Reasons: Residual urine, obstruction, specimen collection, hemodynamic monitoring, prolonged immobilization, and palliative care. - Catheter-Associated Urinary Tract Infection (CAUTI) Prevention ➔ Interventions: ○ Use aseptic techniques. ○ Ensure trained personnel. ○ Choose the smallest catheter size. ○ Secure catheters and maintain sterile drainage systems. ○ Ensure unobstructed urine flow and practice routine perineal hygiene. Catheter Selection and Insertion  - Guidelines for Catheter Selection ➔ Considerations: Size, material, duration of use, medical indication, patient input, anatomical factors, previous catheterizations. ➔ Importance: Proper selection is crucial for patient comfort, complication prevention, and effective drainage. - Catheter Insertion and Documentation ➔ Insertion Skills: Include size selection, balloon inflation, and techniques for straight and indwelling catheters. ➔ Documentation: Record catheterization details, urine output, patient response, and education provided. Catheter Care and Irrigation - Routine Catheter Care ➔ Importance: Prevents infections, blockages, and other complications. ➔ Irrigation Methods: Open, closed, continuous bladder irrigation, and use of triple lumen catheters. - Closed Urinary Catheter Irrigation ➔ Procedure: Maintains sterile connections; can be intermittent or continuous. ➔ Documentation: Essential for irrigation details, output characteristics, patient tolerance, and any adverse events. Catheter Removal and Monitoring - Removal Process ➔ Ensure full deflation of the catheter balloon before removal. ➔ Monitor bladder function post-removal using a bladder scan. ➔ Watch for symptoms of UTI even after removal. ➔ Document time, urine appearance, and condition of the meatus. - Special Considerations for Different Populations ➔ Pediatric: Avoid forcing catheters out if resistance is met. ➔ Gerontological: Recognize atypical signs of CAUTI in older individuals. ➔ Community Care: Involve caregivers in routine catheter care. Bladder Scan and Catheterization - Bladder Scanner: Measures bladder volume and post-void residual (PVR). - Normal Finding: PVR less than 50 ml within 5 to 15 minutes post-voiding. External Catheter Application - Condom-Type External Catheter: ➔ Types: Silicone or latex, secured with adhesive or strap. ➔ Usage: Lower UTI risk compared to indwelling catheters. - Documentation: Application details, skin issues, and urinary patterns. Suprapubic Catheter Care - Care and Maintenance: ➔ Secured with sutures, adhesive, or balloon. ➔ Document urine characteristics and dressing changes. - Output Recording: Document separately for suprapubic and urethral catheters. Gastrointestinal Anatomy and Physiology Review - Bristol Stool Chart and Ideal Bowel Movements ➔ Ideal Types: Type 3 or 4, indicating healthy bowel movements. ➔ Contributing Factors: Adequate fiber, hydration, physical activity, and balanced diet. - Complications of Constipation ➔ Can include fecal impaction, hemorrhoids, anal fissures, and rectal prolapse. - Causes of Constipation and Loose Stool ➔ Constipation Causes: Inadequate fiber, dehydration, lack of activity, medication side effects, medical conditions. ➔ Loose Stool Causes: Infections, food intolerance, inflammatory bowel diseases, excessive alcohol. Treatments and Interventions - Enemas and Rectal Tubes ➔ Enema Purpose: Stimulate bowel movements or administer medication. ➔ Types: Cleansing, retention, and return flow enemas. ➔ Rectal Tube: Helps relieve gas or fecal impaction. - Digital Removal of Stool and Safety Considerations ➔ Purpose: Manually extract fecal impactions. ➔ Process: Use a lubricated, gloved finger to break up hardened stool. ➔ Safety: Avoid injury to the rectal wall and monitor for vagal responses. Gastric Intubation and NG Suction - Gastric Intubation: Involves inserting a tube into the stomach for decompression, feeding, or medication. - Indications: Gastrointestinal bleeding, bowel obstruction, or enteral nutrition. Ostomy Basics - Stomas and Ostomies ➔ Stoma: Surgically created opening for elimination. ➔ Conditions for Stoma: Colorectal cancer, inflammatory bowel disease, trauma. ➔ Types: Colostomy, ileostomy, urostomy/ileal conduit. - Principles for Practice ➔ Colostomy: Produces stool similar to rectal output.  ➔ Ileostomy: Drains watery to thick effluent. ➔ Urostomy: Permanent urinary diversion. Practical Skills and Guidelines - Pouching Colostomy or Ileostomy ➔ Use one or two-piece systems as appropriate. ➔ Document pouch type, change time, effluent appearance, and stoma condition. - Pouching Urostomy ➔ Manage urinary diversion and document pouch type, change time, and urine characteristics. Safety, Collaboration, and Special Considerations - Safety Guidelines ➔ Change pouches before full to prevent leakage. ➔ Recognize signs of healthy stomas and skin. ➔ Wear gloves during care to minimize infection risk. - Delegation and Collaboration ➔ Work with wound, ostomy, and continence nurses for education. ➔ Communicate changes in stoma appearance and output to the healthcare team. - Special Considerations ➔ Tailor teaching to patient needs and provide support for self-care. ➔ Address pediatric and gerontological care requirements. Practice Questions for Chapter 34, 35 and 36 1. Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient? Secure the catheter drainage tubing to the lower leg. Attach the securement device above the catheter bifurcation. Tape the catheter tubing to the lower abdomen, avoiding traction. Secure the catheter tubing to the upper inner thigh with slight traction. 2. What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient? Remove the catheter and start all over with a new kit and catheter. Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. If misplaced, pull the catheter back and reinsert at a different angle. Ask the patient to bear down, and insert the catheter farther.  3. When performing catheter care for a male patient, what step helps prevent traction on the catheter and catheter-associated urinary tract infection (CAUTI)? Wash the meatus with soap and water. Start cleansing at the meatus and move toward the rectum. Grasp the catheter with two fingers to stabilize the catheter. Retract the foreskin before cleansing. 4. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? Daily cleansing of the urinary meatus Hanging the urinary drainage bag at the level of the bladder Changing the urinary drainage bag daily Irrigating the urinary catheter with sterile water 5. Place in appropriate order the following steps related to open intermittent irrigation of a catheter. 1. Position sterile drape under catheter. 2. Open a sterile irrigation tray, establish a sterile field, and pour the required amount of sterile solution into the sterile solution container. 3. Aspirate into irrigating syringe prescribed volume of irrigation solution (usually 30 mL). Place the syringe in a sterile solution container until ready to use. 4. Wipe connection point between catheter and drainage tubing with antiseptic wipe before disconnecting. 5. Disconnect catheter from drainage tubing, allowing any urine to flow into the sterile collection basin. 6. Insert tip of syringe into lumen of catheter and gently push plunger to instill solution. 7. Remove the syringe, lower the catheter, and allow the solution to drain into the basin. 1, 2, 3, 4, 5, 6, 7 2, 1, 3, 4, 6, 5, 7 3, 1, 2, 4, 6, 7, 5 3, 1, 2, 4, 5, 6, 7 6. An immobilized patient has a history of constipation and takes a stool softener at home. Which breakfast selection would be best? Scrambled eggs, bagel with jelly, orange juice Mixed fruit, oatmeal, whole wheat toast Banana, donut, rice cereal with milk Pancakes with syrup, bacon strips, apple juice 7. A patient has a nasogastric tube after abdominal surgery. Which action by the nurse best maintains the patency of the air vent? Irrigating the blue pigtail with 10 mL of air Keeping the blue pigtail above the patient’s stomach Irrigating the blue pigtail with 10 to 20 mL of normal saline Measuring the patient’s nasogastric output twice each shift 8. The nurse is preparing to verify the placement of a patient’s nasogastric tube. Which method of placement verification by the nurse would best indicate that the end of the tube is in the stomach? Checking the pH of the aspirated gastric contents Auscultating the stomach while air is injected into the nasogastric tube Listening for the return of the patient’s bowel sounds Obtaining gastric fluid in the tube when aspirating with a syringe 9. An older patient with limited mobility and strength is recovering from hip surgery and needs to use the bedpan. Which action by the nurse would best facilitate this procedure? Lightly sprinkling a small amount of powder on the bedpan Rolling the patient slightly on his side for better positioning Encouraging the patient to pull up on the overhead trapeze Obtaining the assistance of at least two other staff members 10. An older patient needs to have a fecal impaction removed digitally. The nurse stops the procedure if patient information is obtained? Blood pressure changes from 120/76 to 128/88 Blood pressure changes from 114/78 to 206/70 Heart rate changes from 74 to 58 Heart rate changes from 82 to 96 11. A patient who underwent a urinary diversion yesterday just had his drainage bag emptied of 250 mL of yellow urine with mucus, which was his output for the past 6 hours. What is the appropriate action for the nurse to take? Record output and description of urine. Notify health care providers of low output. Palpate patient’s abdomen. Assess the patient's pain level. 12. A patient asks about what to expect regarding the consistency of stool after his transverse colostomy, to be performed tomorrow. Which response by the nurse best addresses this? “What is your major concern about having the surgery tomorrow?” “The stool will be thin and watery after you establish your eating pattern.”  “The consistency of the stool will vary from thick liquid to semi-formed stool.” “We’ll talk about this at length after you have recovered from the anesthesia.” 13. The patient calls the surgeon’s office 4 weeks after her colostomy was performed, stating that the stoma seems to be shrinking. Which statement by the nurse is most appropriate? “A decrease in the size of the stoma is to be expected.” “Don’t worry about the size of the stoma.” “Because that’s unusual, I’ll let the doctor know.” “As long as the stoma isn’t purple or black, it’s okay.” 14. A female patient who has undergone a colostomy has told you during bathing that she prefers not to have her lower torso exposed. What approach might you use when you need to change the ostomy pouch? Allowing the patient to do as much of her care as she wishes Offering her caregiver the opportunity to participate in care Requiring the caregiver or family to stay with her as much as possible for support Emptying the ostomy pouch when it is full 15. Place in correct order the steps for catheterizing a urostomy. 1. Reapply the pouch. 2. Remove the catheter. 3. Have the patient change position to improve the flow of urine if necessary. 4. Place the distal end of the catheter in a sterile specimen container. 5. Remove the pouch. 6. Cleanse the surface of the stoma using an antiseptic swab. 7. Lubricate the catheter tip. 8. Insert the catheter. 6, 7, 5, 8, 4, 1, 2, 3 5, 6, 7, 8, 4, 3, 2, 1 6, 7, 5, 8, 4, 1, 3, 1 5, 6, 8, 7, 4, 3, 1, 2 Quiz 2 Questions Incorrect Ones 1. The nurse explains the benefits of using cryotherapy for a client with a sprained ankle. Which of the following statements about cryotherapy's benefits is correct? - Local anesthesia is provided - Blood flow is increased - Nerve conduction velocity is increased  - Vasodilation is caused 2. When the skin is exposed to warm or hot temperatures, all of the following occurs except: - Muscle relaxation - Perspiration - Vasodilation - Piloerection 3. Leo, your 35-year-old client has been diagnosed with stomach cancer and is recovering following abdominal surgery. a nasogastric tube has been inserted with tube feedings started 24 hours previously. The Practical Nurse sets up a new enteral feeding bag. The nurse notes that Leo's in Terrell feeding has 150 ml of formula in the bag. His enteral feeding is ordered to infuse at 50 ml an hour. What is a proper response by the nurse? - Recalculate the present drip factor for accuracy - Plan to check the feeding completion within the next 3 hours - Check with pharmacy to see if the formula has been hanging to long - Terminate the fluid and prepare to hang a new bag of formula 4. Which of the following catheter sizes is most suitable for catheterizing an adult female client? - 10 french - 8 french - 14 french - 18 french 5. Catheterization is most commonly performed for which of the following reasons? - Following post-op orders - To obtain a clean catch specimen - To stimulate the kidney - To relieve urinary retention 6. Which of the following options would the nurse expect to note when monitoring a client for symptoms of fluid volume deficit? - Adequate skin turgor - Dry skin and mucous membranes - Crackles in the lungs - Pedal edema 7. In preparation for administering an enema to an adult client who has normal sphincter control, the client is placed in which position? - Dorsal recumbent - Prone  - Left side-lying with right knee flexed - Right side-lying with the left leg flexed 8. Which of the following conditions requires the nurse to exercise additional caution during the digital removal of feces? - Heart disease - Diabetes mellitus - Urinary infection - Abdominal pain 9. Which of the following interventions should be implemented initially prior to your client receiving an enema? - Check for a physician's order - Place the client in a side-lying position - Explain the procedure 10. An appropriate procedure for the nurse to implement while administering an enema is: - Positioning the client on the right side - Lowering the enema bag to increase the flow rate - Keeping the solution at room temperature - Instructing the client to release the solution as soon as possible 11. An order is written for enemas until clear. Which information would cause the nurse to question the healthcare provider's order? - Taking medication for an enlarged prostate - Hemorrhoid surgery 4 weeks ago - Periodic fecal incontinence - A history of glaucoma 12. An 18-year-old female is having difficulty controlling the odor from her colostomy. Which of the following interventions is most appropriate for meeting her needs? - Suggest that she purchased an appliance deodorizer and use it regularly - Encourage her to change the appliance more often - Provide her with the latest equipment in stoma care - Ensure that she understands which foods can cause stronger odors 13. The normal appearance of the stoma of an ileostomy appears: - Dusky blue - Bright red - Dark tan - Pale purple  14. When cleaning the skin around the client's doma, the most appropriate nursing technique is to: - Swab gently with 70% alcohol - Use warm tap water - Pat with cotton balls - Cleanse with peroxide 15. Where is an ileostomy usually located on the abdomen? - On the lower right side - Above the umbilicus - On the lower left side - At the umbilicus of the abdomen 16. When a client has gastric intubation for decompression, the nurse can expect - That the client will always require continuous suction - That the client may have a levin or salem sump tube in place - That the client will always require intermittent suction - That the client has an NG tube connected to oxygen Week 7 - Chapter 9 Specimen Collection Chapter 9: Specimen Collection - Importance of Laboratory Tests ➔ Role in Diagnosis: Laboratory tests provide critical insights into disease states, help monitor disease progression, and evaluate treatment responses. ➔ Timeliness: Prompt collection and sharing of test results with the healthcare team are vital for effective patient care. - Nursing Responsibilities in Specimen Collection ➔ Techniques: Nurses must utilize correct techniques to minimize patient discomfort and ensure safety. ➔ Hand Hygiene: Essential to prevent pathogen exposure during specimen handling. ➔ Patient Privacy: Maintain dignity throughout the process and be sensitive to cultural differences. ➔ Collaboration: Work with the interprofessional team to ensure effective patient care and timely result sharing. - Key Guidelines for Specimen Collection ➔ Blood Specimens: Methods: Include venipuncture (preferred), skin puncture, and arterial puncture.  Culture Samples: For blood cultures, draw from two different sites to confirm bacteremia; ensure specimens are labeled correctly. Avoiding Hemolysis: Vigorous shaking can cause hemolysis, delaying treatment and increasing costs. - Urine Specimens: ➔ Types: Random: For routine urinalysis. Culture and Sensitivity: To identify pathogens. Timed Specimen: Collect all urine over 24 hours to analyze concentrations of substances like glucose and hormones. ➔ Collection Techniques: Educate patients on peri-care, proper positioning, and handling during collection to avoid contamination. - Sputum Specimens: ➔ Collection Methods: Patients may cough into a sterile container or require suctioning if unable to produce a sample. ➔ Testing Purpose: Used to identify conditions like cancer or pulmonary tuberculosis. - Wound Specimens: ➔ Collection Process: Obtain fresh exudate from the center of the wound after removing any old drainage. ➔ Culture Types: Use separate techniques for aerobic and anaerobic cultures to ensure comprehensive microbial analysis. Special Considerations - Cultural Competence: Use gender-congruent caregivers to enhance patient comfort, and be aware of language barriers. - Patient Education: Teach patients about signs of infection and the importance of following collection protocols. - Pediatric and Geriatric Needs: Adjust techniques to accommodate younger patients or the elderly, ensuring proper positioning and emotional support. Procedural Guidelines - Timed Urine Collection: ➔ Collect all urine over 24 hours, ensuring accurate labeling and storage to prevent contamination. ➔ Educate patients about the importance of saving all urine and following collection protocols. - Chemical Properties Screening: ➔ Utilize Multistix reagent test strips for quick assessment of urine properties like pH, protein, and glucose. - Communication and Documentation: ➔ Document the collection process, including any unusual findings and nursing evaluations of both the patient and caregiver.  ➔ Report and document all test results promptly, particularly any abnormalities, to ensure timely interventions. Review Points 1. Urine Specimen Collection: Always verify patient identity using at least two identifiers, assist with peri-care, and instruct the patient to avoid touching the sterile container. 2. Throat Cultures: Position patients appropriately and avoid contact with lips, teeth, and tongue to ensure accuracy. 3. Catheter Urine Collection: Follow the correct order for clamp, clean, aspirate, and unclamp to prevent contamination. 4. Urine pH Expectations: Vegetarians typically have alkaline urine due to their diet, which may influence UTI assessments. 5. Blood Glucose Monitoring in Children: Allow children to choose their puncture site to foster engagement in their care. 6. Femoral Artery Access: This should be performed only by trained professionals due to its complexity and associated risks. Practice Questions for Chapter 9 1. A postoperative patient is suspected of having a wound infection. Which method would be most appropriate for the nurse to use when obtaining an anaerobic culture? Touching the wound edges with the swab from the culture tube Aspirating the drainage using a 21-gauge needle attached to a syringe Using the culture swab, then crushing the attached medium ampoule Aspirating the drainage using the sterile tip of a 10-mL syringe 2. A patient with suspected sepsis is to have blood cultures obtained but s/he is currently receiving antibiotics. What is the most appropriate nursing action? Call the health care provider for further clarification of the order. Stop the scheduled antibiotics until the specimens are drawn. Notify the laboratory which antibiotics the patient is receiving. Scrub the venipuncture site for 2 minutes for a sterile specimen 3. An unconscious elderly patient with poor circulation has to have an arterial blood gas drawn. Which nursing diagnosis would be given priority during and after the procedure? Ineffective airway clearance Impaired gas exchange Risk for injury Deficient knowledge regarding arterial blood gasses 4. A patient needs to expectorate a sputum specimen. The nurse’s teaching has been effective if the patient is seen doing which activity as part of the procedure?  Brushing his teeth with toothpaste before producing the specimen Rinsing his mouth with mouthwash before producing the specimen Providing the specimen immediately after awakening before eating Taking a few sips of water to loosen respiratory secretions 5. A nurse in the diabetic clinic is assessing blood glucose levels in patients ranging from infants to the elderly. Which technique would best ensure that the nurse obtains an adequate amount of blood for testing any of these patients? Hold the area to be punctured in a dependent position. Squeeze the area to be punctured. Cool the area to be punctured. Gently hit the area to be punctured. Week 8 - Chapter 23, 25 O2 Therapy and Airway Management Overview of Oxygen Therapy - Purpose: Oxygen therapy is essential for preventing or treating hypoxia (insufficient oxygen in the blood) and is crucial for conditions like COPD, pneumonia, and respiratory distress. Routes of Administration - Nasal Cannula: Low-flow oxygen; ideal for mild hypoxemia. - Face Masks: Higher oxygen delivery; used for moderate to severe hypoxemia. - Noninvasive Ventilation (NIV): Includes CPAP and BiPAP; supports breathing without intubation. - Positive-Pressure Ventilators: For severe respiratory distress. Principles of Oxygenation - Mechanisms: Oxygen diffuses from alveoli to the bloodstream; adequate hemoglobin levels are vital for effective transport. - Monitoring: Regular assessment of SpO2, vital signs, and patient comfort is crucial. Contraindications and Considerations - Oxygen therapy should be treated as a medication; be aware of patients at risk for respiratory failure. - Environmental assessments are important for safety. Advantages of Oxygen Delivery  - Improves Oxygenation: Enhances blood oxygen levels. - Supports Recovery: Aids in healing and reduces complications from hypoxia. Disadvantages of Oxygen Delivery - Oxygen Toxicity: Prolonged high concentrations can harm lung tissue. - Fire Hazard: Increased risk due to oxygen supporting combustion. Incentive Spirometry - Purpose: Encourages deep breathing to improve lung function. - Types: Flow-oriented and volume-oriented devices. - Usage: Document lung sounds and patient responses; notify nurses of any adverse effects. Noninvasive Positive-Pressure Ventilation (NIPPV) - Types: CPAP and BiPAP; important for patients with respiratory distress. - Education: Patients and caregivers need thorough instruction on machine use and safety protocols. Mechanical Ventilation - Function: Provides support for ventilation; requires close monitoring for alarms and settings. - Preventing VAP: Implement oral care and repositioning as preventive measures. Special Considerations - Pediatric Patients: Provide comfort and secure devices effectively. - Elderly Patients: Be mindful of age-related changes and provide thorough education. Practice Questions For Chapter 23 1. The nurse is providing discharge instructions to a patient regarding the use of a peak flow meter. Which statement by the patient indicates the need for further education? “I should measure my peak flow at the same time every day.” “I should measure my peak flow during asthma symptoms.” “I should measure my peak flow after taking my asthma medication.” “I should measure my peak flow at various times during the day.” 2. Use of noninvasive positive-pressure ventilation (continuous positive airway pressure [CPAP] or bi-level positive airway pressure [BiPAP]) has the potential to cause carbon dioxide retention in selected patients. Patients with which of the following underlying diagnoses are at greatest risk for carbon dioxide retention? Heart failure  Pulmonary fibrosis Chronic obstructive pulmonary disease (COPD) Pulmonary edema 3. A patient with pulmonary edema had bi-level positive airway pressure (BiPAP) started 30 minutes ago. Should the nurse inform the patient that he will undergo a diagnostic test shortly? Arterial blood gas Chest radiograph Pulmonary function test Pulse oximetry reading 4. The low-pressure alarm has sounded on a patient’s ventilator. The nurse should check for which of the following situations? The ventilator circuit has a leak. The patient coughed during the inspiratory cycle. The airway needs suctioning. The patient is biting on the endotracheal tube. 5. A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing the risk for ventilator-associated pneumonia? Performing mouth care at least 4 times a day Repositioning the patient every 2 to 3 hours Assessing lung sounds every shift Performing range-of-motion exercises 3 times a day Chapter 25: Airway Management Overview - Key Concepts ➔ Airway Management Definition: It involves maintaining the patency of the patient's airway—nose, upper airway, trachea, and lower airway. The primary goal is to protect the airway and ensure adequate tissue oxygenation.  ➔ Importance: Effective airway management is critical in various clinical settings, especially in emergency and critical care, to prevent complications like hypoxia and aspiration. - Techniques for Maintaining Airway Patency ➔ Noninvasive Techniques: Hydration Positioning (e.g., postural drainage) Nutrition Chest physiotherapy Deep breathing and coughing exercises Humidity and aerosol therapy ➔ Suctioning: Indicated when patients cannot clear secretions effectively. - Types: ➔ Oropharyngeal Suctioning: For secretions in the back of the throat. ➔ Tracheal Suctioning: For retained secretions in the lower airway. ➔ Equipment: Yankauer suction catheter for oropharyngeal suctioning; sterile techniques for tracheal suctioning. - Artificial Airways: ➔ Endotracheal Tube (ET): Inserted through the mouth or nares for ventilation. ➔ Tracheostomy Tube (TT): Inserted through a neck incision for long-term airway support. Assessment and Monitoring - Know the patient's baseline vital signs and medical history. - Identify patients at risk for aspiration and conduct a thorough pulmonary assessment. - Monitor for potential complications, such as bronchospasm and respiratory depression from medications. Emergency Situations - Be prepared for emergencies, such as airway obstruction, excessive secretions, or trauma. Special Considerations - Communication: Develop alternative communication methods for patients with artificial airways. - Interprofessional Collaboration: Engage with the healthcare team for comprehensive patient care. - Patient and Caregiver Education: Teach airway management techniques for home care, ensuring caregivers are involved in the learning process. Quick Quiz Questions  1. Symptoms of Bronchospasm in a 65-Year-Old Patient: ○ Expected Symptoms: Wheezing and dyspnea. 2. Device to Suction Mucus from an Infant: ○ Correct Device: Bulb syringe. Practice Questions for Chapter 25 1. Which of the following skills can safely be delegated routinely to an unregulated care provider (UCP)? Oropharyngeal suctioning Airway suctioning using a closed method Endotracheal tube care Tracheostomy care 2. Several factors affect the volume and consistency of endotracheal secretions. Which of the following causes an increase in the amount and thickness of secretions? Fluid intake Infection Respiratory rate Humidification 3. Why is it important to assess a patient’s understanding of oropharyngeal suctioning procedure? Encourages cooperation of the patient during and after the procedure Ensures that the patient will be able to perform the procedure themselves next time Prevents secretions from pooling in the upper airway Decreases gag reflex 4. If a patient is accidentally extubated, which of the following actions are appropriate? Attempt to find someone on the unit to assist with reintubation. Suction the patient on an as-needed basis. Assess patients for airway patency, spontaneous breathing, and vital signs. Replace the endotracheal tube. 5. In which order should the nurse initially implement the following steps to complete nasotracheal suctioning with a one-time-use catheter? 1. Have the patient breathe slowly. 2. Gently but quickly insert catheter into nares with suction off. 3. Lightly coat the tip of the catheter with lubricant. 4. In adults, insert a catheter about 20 cm (8 inches) into the trachea. 5. Pick up suction catheter with dominant hand without touching nonsterile surfaces. 6. Increase oxygen flow rate on face masks. 1, 3, 5, 6, 2, 4 1, 3, 2, 4, 5, 6 5, 6, 1, 3, 2, 4 5, 6, 2, 3, 1, 4 Quiz # 3 Questions Incorrect ones 1. Which of the following is an unexpected outcome of oxygen therapy? - Increase in lung expansion - Nasal and upper Airway mucosa drying - Improvement in oxygen saturation levels - Decrease in signs and symptoms of hypoxia 2. Which flow rate of oxygen in liters per minute is delivered via 100% non-rebreather? - 10-15 - 1-6 - 6-8 - 4-8 3. Which of the following is an advantage of using a simple face tent for oxygen delivery? - Deliver 60 to 90% oxygen - Precise Fi02 level can be maintained - Helps provide humidified oxygen - Reservoir bag will maintain optimal 4. Which of the following is most important to monitor if your client is receiving oxygen therapy? - Pain level - Confusion - oxygen saturation levels - intake and output 5. Your client is a CO2 retainer and is receiving oxygen therapy at 2 L per minute via nasal cannula. while in the Supine position he complains of being short of breath. you're most appropriate first action is: - Increase the flow rate of oxygen - Perform oropharyngeal suctioning - Notify the charge nurse  - Assist him to a high Fowler's position 6. When caring for your client with a tracheostomy, his oxygen saturation drops from 92% to 85%. What is your priority nursing action? - Check for patent Airway - Assess for an adequate blood pressure 7. When preparing to begin oxygen therapy for a client the initial action is to - Educate the client to the purpose of this prescribed intervention - Ensure all electrical equipment in the client's room has been certified safe - Place an oxygen in use sign in the appropriate location to alert personnel - Review the medical prescription for delivery method and flow rate 8. A client with COPD has carbon dioxide retention and is to begin oxygen therapy. the nurse anticipates the use of which oxygen delivery system? - Face tent - Face mask - Non-rebreather mask - Nasal cannula 9. A client wearing a nasal cannula of 5 L per minute has skin irritation around his Nares and complains of a dry mouth and nose. Which student nursing action should be questioned by the instructor? - Using humidification - Applying petroleum base gel to the nares - Asking the physician for an order for sterile nasal saline - Providing frequent Oral Care 10. When performing tracheostomy care, you would expect to use which of the following techniques? - Sterile technique for a long-term trach - Clean technique for long-term trach - Clean technique for a new trach - Non sterile technique for all trade care 11. Which of the following is not part of a tracheostomy? - Flange - Inner cannula - Outer cannula - Outer indicator 12. The nurse is teaching a client about their tracheostomy tube. the nurse is providing correct information to the client when they state  - The cuff should be deflated each time the inner cannula is changed - The inner cannula should be cleaned or changed at least twice per day - All tracheostomy tubes are fenestrated - The inner cannula should be cleaned or changed every 6 hours 13. Which of the following is an expected outcome of chest tube in? - Moderate chest pain is ongoing - Partial lung expansion on the affected side - Breath sounds are auscultated in all lung lobes - Drainage from the pleural cavity increases over time 14. When asked to obtain a stool specimen the nurse should - Wear gloves to shake the bed pan content to the specimen container - Put on gloves and scoop a specimen into the specimen container - Bring the bedpan containing the specimen to the lab - Places specimen container inside the bed pen allowing the client to have a bowel movement into the container 15. Which of the following is least true of obtaining a stool specimen? - It is a means of testing for presence of blood - The specimen should be properly labeled - It is always necessary to keep the specimen sterile - Stool specimens can test for parasites 16. Which of the following is an appropriate site for testing a blood glucose level? - An area that has recently been punctured - An edematous area - The central tip of fingers - The lateral aspects of fingers 17. When using test strips, an appropriate procedure for urine testing is to - Obtain the first voided specimen in the morning - Immerse the strip into the urine sample and remove immediately Week 9 - Chapter 29 IV Therapy Chapter 29: Vascular Access and Infusion Therapy Overview - Principles of Practice  ➔ Evidence-Based Care: Safe, efficient vascular access and infusion therapy rely on practices informed by evidence and established guidelines. ➔ Patient Assessment: Thorough assessment of the patient's anatomy, physiology, fluid balance, and medical history is essential. ➔ Device Selection: Choosing the correct vascular access device (VAD) and following proper insertion techniques are critical for success. - Medication Administration: Understanding the 10 rights of medication administration is essential for safe practice. Indications for IV Therapy - IV therapy is indicated for: ➔ Fluid Replacement: For dehydration, shock, or significant fluid loss. ➔ Medication Administration: For rapid onset or continuous delivery of medications. ➔ Nutritional Support: For patients unable to eat or absorb nutrients (e.g., TPN). ➔ Electrolyte Correction: To address imbalances like hyponatremia or hyperkalemia. ➔ Blood Product Transfusion: For conditions like anemia. - Goals and Desired Outcomes: ➔ Restore fluid and electrolyte balance. ➔ Effectively deliver medications. ➔ Maintain nutritional needs. ➔ Monitor patient responses to therapy. Complications of IV Therapy - Common Complications: ➔ Infection: Local or systemic. ➔ Phlebitis: Inflammation of the vein. ➔ Infiltration: IV fluids leaking into surrounding tissue. ➔ Extravasation: Leakage of irritant medications into surrounding tissue. ➔ Air Embolism: Entry of air into the bloodstream. ➔ Thrombosis: Clot formation in the vein. - Nursing Actions for Complications: ➔ Infection: Monitor for signs of infection; maintain aseptic technique. ➔ Phlebitis/Infiltration: Stop infusion, remove IV, and apply compresses. ➔ Extravasation: Administer antidote if available; consult provider. ➔ Air Embolism: Position patient on the left side, monitor vitals, and administer oxygen. ➔ Thrombosis: Assess and report symptoms; may require anticoagulation. Client Teaching - Explain the purpose and process of IV therapy. - Inform patients about sensations during insertion (e.g., pressure). - Teach signs of complications to report (e.g., redness, swelling). - Emphasize the importance of reporting discomfort or changes. Important Assessments - IV Site: Check every 1-2 hours for signs of infection, phlebitis, or infiltration. - Fluid Balance: Monitor intake/output, weight, and vital signs. - Complications: Regularly assess for swelling, redness, or warmth. - Patient Response: Monitor for therapeutic effects of medications or fluids. Documentation - Key elements to document include: ➔ Date and time of IV initiation. ➔ Type and amount of fluids or medications infused. ➔ Patient's response and any adverse reactions. ➔ Assessment findings related to the IV site and patient condition. ➔ Any complications and interventions taken. Infection Prevention - Perform hand hygiene before assessments or care. - Use aseptic non-touch techniques and approved antiseptic solutions (e.g., chlorhexidine gluconate) for skin cleansing before insertion. - Allow antiseptic to dry completely before insertion and dressing application. - Monitor the insertion site every 4 hours in the hospital; daily in the community. Nurse Safety During IV Care - Use aseptic techniques and personal protective equipment (PPE). - Ensure safe equipment handling and training. - Be aware of the environment and position patients safely. - Communicate effectively and monitor for complications. Intravenous Catheters - Types: VADs can be peripheral or central, depending on where the catheter tip resides. - Selection Factors: Consider therapy type, duration, patient characteristics, and resources available. - Locking: Short peripheral IVs can be locked with preservative-free saline or heparin based on specific protocols. Complications of Vascular Access Devices - Complications to Monitor: ➔ Catheter damage or breakage. ➔ Occlusions (thrombotic, mechanical, etc.). ➔ Infection and sepsis. ➔ Dislodgement or migration.  ➔ Loss of skin integrity (hematoma, redness). ➔ Infiltration, extravasation, and serious complications like pneumothorax. Catheter Sizing - 14, 16, 18 Gauge: For trauma, rapid fluid replacement, and blood transfusions. - 20 Gauge: For continuous or intermittent adult infusions and blood transfusions. - 22 Gauge: Suitable for various age groups and infusion needs. - 24 Gauge: For smaller veins in all populations. Lab Multiple Choice Worksheet 1. Intravenous fluids are administered for the purpose of: a. Providing nutrition. b. Maintaining fluid balance c. Restoring lost fluids & electrolytes. d. Only “a” and “c” are correct. e. All of the above 2. Veins: a. Do not pulsate. b. Have thick muscular walls. c. Carry blood away from the heart. d. Are deep within the subcutaneous tissue. 3. Needles and cannula for IV therapy: a. Are made of stainless steel or this flexible plastic. b. Is determined based on patient age, health and fluid to be infused. c. Are sized by gauge; the higher the number, the smaller the diameter. d. All of the above answers are correct. e. “b” and “c” are correct. 4. A “lock” is a device which: a. Restricts the movement of the patient. b. Allow administration of intermittent IV fluid or drugs. c. Are normally filled and flushed with a saline solution. d. Are used for patients who require continuous iv fluids. e. Only “b” and “c” are correct. 5. Prevention of contamination of IV equipment is extremely important. Which of the following does the nurse implement to reduce risk of cross-contamination? a. Calculate and monitor I.V. flow rate. b. Cleanse hands prior to handling equipment. c. Examine the solution for cloudiness or discoloration. d. Always check I.V. label and the expiry date of the fluids. 6. Signs and symptoms of infiltration include: a. Pain and burning at the site. b. Swelling and pale discoloration to the area surrounding the site. c. Difficulty in maintaining the proper flow rate. d. Only “a” and “b” are correct. e. “a”, “b”, and “c” are correct. 7. a. Isotonic solutions are those that have the ___same______ osmolality as the body fluids. b. Hypotonic solutions are those that have an osmolality that is ___less than__ that of body fluids. c. Hypertonic solutions are those that have an osmolality that is __greater than__ that of body fluids. 8. Clinical assessment of dehydration would be confirmed if the nurse identified which of the following? a. 450g weight loss b. Engorged neck vessels c. Dry mucous membranes d. Full bounding radial pulse 9. The nurse anticipates that the physician will order which hypotonic intravenous (IV) fluid for a client who is dehydrated? a. 3% Sodium chloride b. 0.9% Sodium chloride c. 0.45% Sodium chloride d. Lactated Ringer’s solution 10. The nurse is conducting an assessment of an elderly client receiving IV fluids. Today is March 9. The tubing is dated March 5. The nurse determines which of the following about the tubing? a. Consult a physician for further directions. b. It should remain in place as long as possible. c. It is good for 3 more days, for a total of 7 days. d. It needs changing because it is beyond the 3-day limit. 11. Which of the following activities can be properly delegated to an unregulated care provider? (Select all that apply.) a. Measuring intake and output b. Reporting that an IV bag is low in fluid c. Preparing intravenous (IV) tubing for systematic change d. Discontinuing an IV infusion per health care professional orders  12. Assessment data indicating intravenous (IV) fluid infiltration include which of the following? (Select all that apply.) a. Edema and pain b. Pain and erythema c. Pallor and coolness d. Numbness and pain e. Phlebitis and coolness 13. A physician orders that the client receive 300 mL of normal saline to be infused over 20 minutes. The drip factor is 10 drops/mL. The nurse adjusts the drop to _____ drops per minute. V/T x gtt factor= 300ml/20 min x 10 gtt/ml= 150 gtt/min Week 10 - Chapter 30 Blood Therapy Chapter 30: Blood Therapy Overview - Reasons for Blood Therapy - Patients may require blood therapy for various medical conditions, including: ➔ Anemia: To increase red blood cell count and improve oxygen delivery. ➔ Blood Loss: Due to trauma, surgery, or significant hemorrhage. ➔ Coagulation Disorders: To manage conditions affecting blood clotting. ➔ Cancer Treatment: Often needed for patients undergoing chemotherapy or radiation. ➔ Bone Marrow Disorders: Such as aplastic anemia or myelodysplastic syndromes. ➔ Severe Infection or Sepsis: To restore blood volume and improve oxygenation. ➔ Heart Conditions: To enhance blood oxygen levels and circulation. ➔ Thalassemia or Sickle Cell Disease: To manage chronic anemia and complications. ➔ Pregnancy Complications: Such as hemorrhage or anemia. ➔ Organ Transplant: To maintain adequate blood volume and clotting function. Blood Components - Blood is separated into specific components for transfusion, including: ➔ Red Blood Cells (RBCs): Used to treat anemia and restore blood volume. ➔ Platelets: Essential for clotting; used for patients with low platelet counts. ➔ Plasma: Contains proteins and is used to treat clotting disorders. ➔ Cryoprecipitate: Rich in clotting factors; used for hemophilia or significant bleeding. ➔ Albumin (5% and 25%): Used for volume expansion and maintaining oncotic pressure. ➔ Intravenous Immune Globulin: Provides antibodies to help fight infections. ➔ Prothrombin Complex Concentrate: Used for patients with bleeding disorders. Blood Type and Cross-Matching - Blood Type: Based on the presence of antigens on red blood cells (types A, B, AB, O, Rh-positive, or Rh-negative).  - Cross-Matching: A laboratory test to ensure compatibility between donor and recipient blood, preventing agglutination reactions. Risks of Blood Therapy - Common risks associated with blood transfusions include: ➔ Allergic Reactions: Range from mild hives to severe anaphylaxis. ➔ Febrile Non-Hemolytic Reaction: Fever and chills due to immune response to donor white blood cells. ➔ Hemolytic Reactions: Acute Hemolytic Reaction: Due to ABO incompatibility; causes rapid destruction of RBCs. Delayed Hemolytic Reaction: Occurs days to weeks post-transfusion from minor incompatibility. ➔ Transfusion-Related Acute Lung Injury (TRALI): Rare condition causing sudden respiratory distress. ➔ Transfusion-Associated Circulatory Overload (TACO): Fluid overload, especially in patients with heart failure or renal issues. ➔ Infections: Although rare, there’s a risk of transmitting infections like HIV and hepatitis. Transfusion Reactions - Understanding how to manage transfusion reactions is crucial: ➔ Mild Allergic Reaction: Symptoms include itching and hives; managed with antihistamines. ➔ Febrile Reaction: Fever and chills; treated with antipyretics and monitoring. ➔ Acute Hemolytic Reaction: Symptoms like fever, chills, and dark urine; requires immediate cessation of the transfusion and supportive care. ➔ Delayed Hemolytic Reaction: Symptoms may include mild jaundice; managed with supportive care. ➔ TRALI: Symptoms include sudden respiratory distress; requires oxygen therapy and possibly ventilatory support. ➔ TACO: Symptoms like dyspnea and hypertension; managed with diuretics and supportive care. Chapter 30 Practice Questions 1. Which of the following is considered a primary cause of transfusion reactions? Use of mislabelled unit Use of 0.9% normal saline (NS) Use of leukocyte reduction filter Use of Y tubing 2. Blood obtained from the blood bank must be used within what time limit? 10 minutes  20 minutes 30 minutes 60 minutes 3. One unit of packed red blood cells (PRBC) can hang no longer than 1 hour. 2 hours. 3 hours. 4 hours. 4. Onset of TRALI (transfusion-related acute lung injury) can occur within 6 hours of transfusion. True False Week 11 - No chapter - Orthopedic Care Orthopedic Care: Key Procedures and Protocols - Key Procedures 1. Cast Application ○ Description: Immobilizes an injured area to promote healing. Types include plaster, fiberglass, and others suited for different conditions. 2. CMS Assessment ○ Description: A systematic evaluation of Circulation, Motor, and Sensory functions to monitor the status of the extremity after cast application. 3. Cast Removal ○ Description: Involves explaining the procedure to the client and focusing on post-removal skin care and range of motion exercises. - Key Complications ➔ Neurovascular Compromise: Compression of nerves and blood vessels, potentially leading to loss of function. ➔ Skin & Tissue Breakdown: Occurs if the cast is too tight or moist, leading to infection or irritation. ➔ Hidden Bleeding: May occur without visible signs; requires careful monitoring of vital signs and symptoms. - Interventions ➔ Positioning: Ensure proper positioning to promote healing and comfort. ➔ Client Education: Inform clients about expectations, cast care, and signs to report. ➔ Monitoring: Regular assessment of the cast and the client's neurovascular status, especially within the first 24 hours. - Key Assessment Techniques  ➔ CMS Checks: Assess circulation, motor function, and sensory perception to ensure limb integrity after cast application. ➔ Observation for Complications: Monitor for signs of swelling, pain, or changes in skin color. Facts to Memorize - Types of Casts: Plaster of Paris, Synthetic (fiberglass), Acrylic, Fiberglass-free, Latex-free polymer. - Assessment Frequency for CMS: ➔ Every 2 hours for the first 12 hours ➔ Every 4 hours for the next 48 hours ➔ Then every 8 to 12 hours as needed. Principles of Traction - Maintain the line of pull. - Ensure proper maintenance of traction equipment. - Maintain countertraction. - Use continuous traction unless otherwise ordered. - Maintain correct body alignment. - Prevent friction against the skin. Reference Information - Common Types of Traction: ➔ Skin Traction ➔ Skeletal Traction ➔ External Fixators - Potential Complications of Casts: ➔ Hidden bleeding ➔ Neurovascular compromise ➔ Acute compartment syndrome ➔ Skin or tissue breakdown ➔ Hidden infection from wounds or ulcers. Concept Comparisons Concept Skin Traction Skeletal Traction Definition Pulling force applied directly to skin Involves pins and devices for and soft tissue immobilization Duration Temporary, until surgical repair Longer-term, often for multiple traumas  Common Immobilizes fractures, relieves muscle Used less frequently due to advanced Uses spasms surgical practices Examples Buck’s Extension, Dunlop’s Traction Balanced-suspension traction CMS Assessment Steps 1. Gather Equipment and Wash Hands: Ensure all necessary materials are ready and hygiene is maintained. 2. Explain the Procedure to the Patient: Provide a clear description to ease anxiety. 3. Assess Circulation: ○ Compare skin color to the unaffected extremity. ○ Check the temperature of both extremities. ○ Assess capillary refill time (should be