Fundamentals of Nursing Lecture Notes

KRISTINA MARIE PARULAN-ANDAYA, BSN, PHRN, USRN University of the Philippines- Master of Arts in Nursing (Major in Adult Health Nursing) Bulacan State University- Bachelor of Science in Nursing Illinois Board of Nursing-Passed (Stopped at 75 questions) PH License No: 0633805 US License No (...

KRISTINA MARIE PARULAN-ANDAYA, BSN, PHRN, USRN University of the Philippines- Master of Arts in Nursing (Major in Adult Health Nursing) Bulacan State University- Bachelor of Science in Nursing Illinois Board of Nursing-Passed (Stopped at 75 questions) PH License No: 0633805 US License No (Illinois): 041532751 US License No (New Mexico): 78320 PTE Academic-Passed (Pearson Test of English) NCLEX-RN Lecturer and Professor Trainer and Mentor (Nursing Education, Sales, Leadership and Management for over 14 years)  NURSING PROCEDURES KRISTINA MARIE PARULAN, PHRN, USRN KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ZOOM ETIQUETTE GUIDELINES Mute your microphone all the time, chat box is the only medium of communication, participate in the class using chat box. Be mindful of background noise and distractions around you, as much as possible. Adjust your camera and lighting so we can see your face well. Dress like you are coming to the classroom—no jammies, please. Avoid multi-tasking and focus your attention on the class. Enjoy a beverage but hold off on having lunch or that snack. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ZOOM ETIQUETTE GUIDELINES All comments and discussions should be respectful of the instructor and fellow students; disagreements are fine, but personal attacks are not. Get the attention of the speaker if the mic/ graphic pen/presentation is not working. Remember that you are always on camera. All of the questions will be entertained at the end of the discussion by typing it in the chat box. The chat window should be used only for class-related discussions—comments, sharing of resources, etc.—except for casual conversations at the start and end of class. Keep remarks on-topic and courteous. Remember that this is still our classroom. Use the screenshot function to copy the lecture. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN PRE-TEST KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 1. Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins. C. List of priorities is determined. D. Review of the assessment is conducted with other team members. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 2. For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyper oxygenate before and after suctioning B. Repeat suctioning until the tube is clear C. Apply suction during insertion of the tube D. Suction for 30 seconds KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 3. Which of the following interventions will help lessen the effect of GERD (acid reflux)? A. Elevate the head of the bed on 4-6 inch blocks. B. Lie down after eating. C. Increase fluid intake just before bedtime. D. Wear a girdle. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 4. Matteo is diagnosed with dehydration and underwent a series of tests. Which laboratory result would warrant immediate intervention by the nurse? A. Serum sodium level of 138 mEq/L B. Serum potassium level of 3.1 mEq/L C. Serum glucose level of 120 mg/dl D. Serum creatinine level of 0.6 mg/100 ml KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 5. A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? A. Side-lying with a pillow under the hip B. Prone with a pillow under the abdomen C. Prone in slight Trendelenburg’s position D. Side-lying with the legs pulled up and the head bent down onto the chest KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ABDOMINAL ASSESSMENT determine the presence of mass, abnormal Purpose: bowel sounds, lesions, and other abnormalities in the abdominal region (IAPePa) Inspection, Nursing Key points: Auscultation, Percussion, Palpation Position: Dorsal Recumbent Start palpating from RLQ, RUQ to LUQ, to LLQ No to palpation to patients with Wilm's tumor and abdominal Aortic Aneurysm KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take? 1. Start the client on sips of water. 2. Remove the nasogastric (NG) tube. 3. Call the primary health care provider immediately. 4. Document the finding and continue to assess for bowel sounds. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  Best Time to Collect: Early in the Morning 6am URINALYSIS (+) protein: PIH, nephrotic syndrome (+) glucose: diabetes mellitus, infection Purpose: to assess characteristics of urine Nursing Key points: first voided morning sample preferred: 15 ml (-) blood, glucose, ketones, CHON Color: Straw/ Amber /Albumin Odor: Aromatic decreased specific gravity: diabetes insipidus pH: 4.5-8.0 increased specific gravity: diabetes Specific Gravity: mellitus, dehydration, SIADH KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 1.010-1.025 CULTURE & SENSITIVITY Purpose: Confirmatory test for UTI Nursing Key points: 1. Clean catch/ midstream: clean---void---catch---void--- clean 2. Catheterized Urine- clamp—clean– collect ---------- sterile syringe (below the port 30 min-1hr) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN URINARY CATHETERIZATION Purpose: To determine residual urine and obtain sterile specimen Nursing Key points: the procedure is sterile maintain a close system the drainage bag must always be below the bladder to avoid back flow of urine the catheter bag should not be allowed to lie on the floor do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it provide urine acidification KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  URINARY CATHETERIZATION Male Female Position: Supine Dorsal Recumbent Size: French 16-18 French 14-16 Length: 6-8 inches 2-4 inches Tape: Lower Abdomen Inner Thigh Outer Thigh KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN TIMED COLLECTION 24 Hr urine collection (Schilling’s Test), Creatinine Clearance Purpose: Test, VMA Test (Pheochromocytoma) Nursing Key points: Sample: Sept 2, 8AM- 1st VOID (DISCARD) 10 AM- 2nd VOID ( COLLECT ) Sept 3, 8AM- Last VOID (Collect) *Should be refrigerated / cooler KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ROUTINE SPECIMEN (GENERAL PRINCIPLES): 1. Usually collected in early morning before intake of food and fluids; if done in fasting state, withhold food and fluids for 8–12 hours prior to test 2. Collect using standard precautions to protect against exposure to blood or other body fluids; use strict aseptic technique to protect client from infection 3. Label specimens with client name, date, exact time of collection, and type of specimen 4. On laboratory requisition slip, note client identifying information as per agency policy, possible diagnosis, and test (or tests) being requested; record any factors that could interfere with results, such as foods or prescribed drugs 5. Avoid shaking blood specimens to avoid hemolysis and send promptly to lab 6. Values that fall within laboratory reference range are considered normal 7. Critical (panic) values are abnormal results that could increase risk of harm to client; these are sent immediately to nursing unit and must be reported to charge nurse and/or healthcare provider KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  24- HOUR URINE SPECIMEN (GENERAL PRINCIPLES): 1. Obtain a 24-hour specimen collection container (with preservative if indicated) from lab 2. Label container with client’s name, date, test, and time started and time completed (e.g., 12/29/17 08:00 to 12/30/17 08:00); place container on ice if indicated 3. Place 24-hour specimen collection sign above client bed, in bathroom, and on chart or electronic health record as a reminder to save all urine collected during specified time period 4. At beginning of collection period, have client void and discard this urine; save all urine for next 24 hours 5. Instruct client to void each time into container, such as a specimen hat, and avoid contaminating specimen with feces or bathroom tissue 6. Transfer voided specimen into collection device using standard precautions 7. At end of collection time, have client void and save this specimen 8. Complete laboratory requisition and send urine collection to lab; document specimen completion and pertinent observations of urine in client record KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client? 1. Check the specific gravity of the urine. 2. Clamp the tubing for 30 minutes and then release. 3. Provide suprapubic pressure to maintain a steady flow of urine. 4. Raise the collection bag high enough to slow the rate of drainage. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  Purpose: STOOL ANALYSIS Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  assessment of bacteria, virus, malabsorption and blood in the stool ROUTINE FECALYSIS NURSING KEY POINTS: -Clean surface - Presence of blood, mucus, kakaiba (collect) - Middle portion of stool - 1 inch or 1 tsp - Diarrhea (10-15ml) - Collect within 1 hr or ASAP KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  Purpose: GI bleeding Nursing Key points: FECAL OCCULT BLOOD FALSE (+) RESULT FALSE (-) RESULT TESTING *Avoid dark colored foods for 3 days Avoid VITAMIN C 500mg (FOBT) *Avoid iron, anti coagulants, GUIAC’S TEST NSAIDs, Corticosteroids (7 days prior to specimen Collection) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN FAT ANALYSIS Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  -ABC (Airway, Breathing, Circulation) SPUTUM EXAM determines the presence of Purpose: microorganisms in the sputum Nursing Key points: Oral care: instruct patient to rinse mouth with water ( no to mouth wash or tooth paste) amount required: 15 ml DBE: to loosen mucus/ sputum--instruct the patient to take several deep breaths and then cough deeply Instruct the px to HACK UP and COUGH OUT KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  -Acid Fast Bacili AFB: -PTB -monitor effectiveness of the Tx CULTURE & SENSITIVITY: -confirmatory of PTB CYTOLOGY Lung Cancer KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN Which actions should the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply. 1. Explain the procedure to the client. 2. Obtain the specimen early in the morning. 3. Have the client brush his teeth before expectoration. 4. Instruct the client to take deep breaths before coughing. 5. Place the lid of the culture container face down on the bedside table. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN BREAK: PLEASE BE BACK AT 3:15 PM KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN GASTRIC ANALYSIS Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN NASOGASTRIC TUBE Gavage (Feeding) Lavage (irrigation) Purpose: Decompression Medication Nursing Key points: Feeding: Semi Fowler during and after feeding until 30 min Rubber Tubing- submerge into ice/ cold H20 Removal: Semi Fowler (Hold Plastic: KY Jelly breathe while being removed) Insertion: High Fowler/ Sitting ( Head is hyper extend, flex and lean forward) Ask to swallow if possible KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN TOTAL PARENTERAL NUTRITION Carbs, Lipids/fats, proteins and electrolytes Intravenous ACCESS: Central- most common site - SUBCLAVIAN VEIN (Primary) - Jugular Vein Insertion: site should be lower than the body (Trendelenburg ) to avoid Pulmonary Embolism Purpose: -IBD -Severe Burns -Malnutrition -Pancreatitis Removal: Same Position + Valsalva Maneuver KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  TOTAL PARENTERAL NUTRITION Complications: 1. Hyperglycemia- rapid infusion / Regular Insulin (Humulin R) only insulin via IV 2. Hypoglycemia- abrupt STOP of TPN- d10 should be available (dextrose 10%) 3. Sepsis/ infections- site+glucose- must maintain strict aseptic technique, antibiotics (prophylaxis) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client? 1. Death is imminent. 2. The client will need to adjust to the idea of living without eating by the usual route. 3. Total parenteral nutrition requires disfiguring surgery for permanent port implantation. 4. Nausea and vomiting occur regularly with this type of treatment and will prevent the client from participating in social activity. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client? 1. Track the client's oral temperature. 2. Administer antibiotics intravenously. 3. Evaluate the differential of the leukocytes. 4. Use sterile technique for dressing changes. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  SUCTIONING -belongs to Respi Procedure (Sterile Gloves) hyperoxygenate the patient before and after the procedure apply intermittent suction on withdrawal of the catheter do not suction the patient for more than 5 min. Change every after use. PURPOSE: NURSING KEY POINTS: to obtain sputum sample and clear the airway KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN -BVM (AmbuBag)- 3 Hyperinflation -O2 Tank- 10-15L/min (1 full min before suctioning) -Mechanical Ventilator- F1O2 (100%) 2 min before suctioning SUCTIONING Complication: HYPOXIA-most common (hyperoxygenation) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  ROUTES OF SUCTIONING ORO NASO ET/TT SF/ Head turned SF/ Head hyper POSITION (Conscious) SF at side extend POSITION (Unconscious) Side lying/Lateral Side lying/Lateral Side lying/Lateral Tip of Nose to Nose to Earlobe (4-6 insert until resistance Length Earlobe (4-6 inches) met, withdraw 1 inch inches) - 5 to 10 seconds; - 5 to 10 seconds; max Timing 5-10 sec max 15 sec 15 sec Interval - 20 to 30 sec - 20 to 30 sec 2-3 min KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  TYPES OF SUCTION PORTABLE WALL TYPE INFANT 2-5 mmHg 50-95 mmHg CHILD 5-10 mmHg 95-110 mmHg ADULT 10-15 mmHg 100-120 mmHg KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN INCENTIVE SPIROMETER Purpose: SMID (Sustain Maximum Inhalation Device) -Post Op Patients to prevent Pulmonary Complications(Atelectasis) -CAL (Chronic Airflow Limitation) Nursing NursingKey points: Keypoints: -Upright or Sitting Position -done 4 to 5 times a day/10 sessions each) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN INCENTIVE SPIROMETER - Give Meds (pain because they are post op patients) - Splinting of incision site Pre- Procedure: 1. Exhale fully and seal the lips into mouthpiece Procedure: 2. Inhale slowly and steadily (Flow indicator: BETTER/ BEST), hold breathe 2-6 seconds 3. Exhale normally KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN INCENTIVE SPIROMETER Nursing Care (POST): -DBE -Oral Care - Wash the mouthpiece with water KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse instructs a preoperative client about the proper use of an incentive spirometer. What result should the nurse use to determine that the client is using the incentive spirometer effectively? 1. Cloudy sputum 2. Shallow breathing 3. Unilateral wheezing 4. Productive coughing KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN TRACHEOSTOMY Purpose: artificial airway KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN PARTS KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN NURSING CARE (TRACHEOSTOMY) Sterile Technique Inner Cannula- SOAK (Hydrogen Peroxide/ Half Strength), RINSE (NSS), DRY (Tap Dry, AVOID Gauze) RE INSERT INNER CANNULA: 9 o clock to 6 o clock Expiration of NSS: once opened 24 hrs only KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  NURSING CARE (TRACHEOSTOMY) 2. GLOVES- clean gloves at first (getting the inner cannula) then Sterile Gloves while cleaning 3. Tracheostomy Ties- secure the outer cannula - Tie, Tie, Knot, Knot (NEW) - Untie, Untie (OLD) - -Insert 1 finger before knotting 4. Tracheostomy cuff- airtight seal to prevent aspiration 5. Outer Cannula Dislodgement- maintain patent airway KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  AT BED SIDE: 1. Obturator 2. Sterile Forceps 3. Suction 4. Trach Set 5. Magic Slate KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure? 1. Breath sounds 2. Capillary refill 3. Respiratory rate 4. Oxygen saturation level KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight? 1. The client nods that he or she feels comfortable. 2. Two fingers can be slid comfortably under the holder. 3. Four fingers can be slid comfortably under the holder. 4. The tracheostomy does not move more than 0.5 inch when the client coughs. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure? 1. Suction kit and tracheostomy dressing 2. Bottle of sterile saline and a tracheostomy care kit 3. Bottles of sterile saline and water and a tracheostomy dressing 4. Tracheostomy care kit, sterile saline and water, and a suction kit KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  CHEST TUBE DRAINAGE/ CTT / CHEST TUBE Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  CHEST TUBE DRAINAGE/ CTT / CHEST TUBE KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN PROBLEMS WITH CTT KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CHEST PHYSIOTHERAPY KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CHEST PHYSIOTHERAPY Percussion Vibration KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  BP- Hypotension 1kg- 1L Shock Like Manifestation HR/PR-Tachycardia RR-Tachypnea PARACENTESIS Purpose: to assess the contents of the peritoneal fluid Nursing Key points: check for consent patient is weighed before and after procedure instruct the patient to void prior to the procedure to prevent accidental puncture of the bladder during the procedure, instruct the patient to sit up with feet resting on footstool evaluate the effect of the procedure by assessing – weight, abdominal girth, respiratory rate/pulse rate notify the physician if the urine becomes bloody, pink or red KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN THORACENTESIS Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  LUMBAR PUNCTURE to withdraw CSF to determine Purpose: abnormalities Nursing Key points: before the procedure: empty bladder and bowel position: C-position (fetal position) after: position the patient flat for 6-12 hours to prevent spinal headache increase fluid intake KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN BARIUM ENEMA Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN BARIUM SWALLOW Purpose: Nursing Alert: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN BONE MARROW BIOPSY aspirating bone marrow for laboratory studies. Purpose: Preferred site is the iliac crest (proximal tibia in children), but may also use sternum, iliac spine Nursing Key points: administer sedative as ordered positioning (prone for iliac crest) pressure on the site for 5 to 10 minutes after aspiration placed on affected side (with sandbag underneath) assess for discomfort and bleeding at the site KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  CARDIAC CATHETERIZATION To measure oxygen concentration saturation, tension Purpose: and pressure in various chambers of the heart. To determine a need for cardiac surgery. Nursing Key points: check for informed consent assess allergy to iodine NPO for 6-8 hours before procedure check for distal pulses after the procedure check for bleeding at the arterial puncture site and apply pressure keep a 20 pounds sandbag at the bedside as a pressure instrument if bleeding occurs keep the patient flat on bed with the lower extremities hyperextended for 4-6 hours neurovascular assessment must be performed distal to the catheter insertion site and report any abnormal KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN findings A client is scheduled to undergo a renal biopsy. To minimize the risk of post procedure complications, the nurse should report which laboratory result to the health care provider before the procedure? 1. Potassium: 3.8 m Eq/L (3.8 mmol/L) 2. Prothrombin time: 15 seconds (15 seconds) 3. Serum creatinine: 1.2 mg/dL (106 mcmol/L) 4. Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN Which action should the nurse implement as part of care for a client after a bone biopsy? 1. Monitoring the vital signs once per day. 2. Keeping the area in a dependent position. 3. Administering intramuscular opioid analgesics. 4. Monitoring the site for swelling, bleeding, or hematoma formation. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CHEST X-RAY PURPOSE: NURSING KEY POINTS: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CYSTOSCOPY Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CT SCAN Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety? 1. Allergies 2. Familial renal disease 3. Frequent antibiotic use 4. Long-term diuretic therapy KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN CVP (CENTRAL VENOUS PRESSURE) MONITORING PURPOSE: NURSING KEY POINTS: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ELECTROCARDIOGRAM (ECG) Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN ELECTROENCEPHALOGRAM (EEG) Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  Purpose: FASTING BLOOD SUGAR (FBS) Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN INTRAVENOUS PYELOGRAPHY (IVP) Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN LIVER BIOPSY Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN MAMMOGRAPHY Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN MANTOUX TEST Purpose: a test to determine exposure to TB Nursing Key points: a positive test yields an induration of 10 mm. or more for foreign born children below 4 years old an induration of 5 mm or more is considered positive in patients with HIV, with treated TB, and if he has had a direct exposure TB patients BCG may cause false positive reaction assess for previous history of PTB and report immediately to the doctor result is read after 48-72 hours KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  Purpose: MRI (Magnetic Resonance Nursing Key points: Imaging) KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN RINNE’S TEST Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN  SWAN-GANZ CATHETERIZATION Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN TONOMETRY Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN WEBER TEST Purpose: Nursing Key points: KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 3. The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position? 1. High Fowler's 2. Trendelenburg’s 3. Lateral recumbent 4. Reverse Trendelenburg's KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 5. A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter? 1. Monitor urine output every shift. 2. Measure specific gravity once a shift. 3. Encourage a high intake of oral fluids. 4. Avoid kinking of the catheter tubing. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 6. Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply. 1. Use strict aseptic technique. 2. Place the drainage bag lower than the bladder level. 3. Inflate the balloon with 4 to 5 mL beyond its capacity. 4. Swab the urinary catheter with sterile water before inserting. 5. Advance the catheter 1 to 2 inches after urine appears in the tubing. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 7. The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next? 1. Inflate the balloon with water. 2. Secure the catheter to the client. 3. Measure the initial urine output. 4. Advance the catheter 2.5 to 5 cm. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 8. A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction? 1. Cleanse the perineal area with soap and water once a day. 2. Keep the drainage bag lower than the level of the bladder. 3. Limit fluid intake so that the bag will not become full so quickly. 4. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder. KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 10. The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, "I really miss eating dinner with my family. Which statement from the nurse is the most therapeutic? 1. "What you are feeling is very common." 2. "Tell me more about your family dinners." 3. "In a few weeks, you may be allowed to eat." 4. "You can sit down to dinner even if you do not eat." KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 12. The nurse preparing to admit a 7-month-old infant with febrile seizures should anticipate the need for which equipment when planning care for this infant? 1. Restraints at the bedside 2. A code cart at the bedside 3. Suction equipment and an airway at the bedside 4. A padded tongue blade taped to the head of the bed KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN 17. Which type of anemia is diagnosed with a Schilling test? 1. Aplastic 2. Pernicious 3. Megaloblastic 4. Iron deficiency KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN POST- TEST KRISTINA MARIE PARULAN-ANDAYA, PHRN, USRN