Micep Black

7/31/2019 Micep Black

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Editor Medical Surgical Nursing

Associate Professor of Nursing

University of Nebraska Medical CenterOmaha, NE

CLIENT SAFETY, SECURITY & PRIVACYREQUIREMENTS in MEDICAL-SURGICAL

NURSING PRACTICE


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Test Plan Structure Safe and Effective Environment

Health Promotion/ Maintenance

Psychological Integrity

Physiological Integrity Pharmacological Intervention

Reduction of Risk

Items written based on usual activities ofnurses one year after graduation


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Safe Effective Care Environment Management of Care 13-19%

Safety and Infection Control 8-14%

Health Promotion and Maintenance 6-12%

Psychosocial Integrity 6-12%

Physiological Integrity Basic Care and Comfort 6-12%

Pharmacological and Parenteral Therapies 13-19% Reduction of Risk Potential 13-19%

Physiological Adaptation 11-17%


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Multiple Choice Single right answer

Multiple Answer More than 1 right answer

The item will indicate that more than one answer is right

Fill in the Blank Usually math

Hot Spot Location of something on a figure

Eg, location of apical pulse Exhibit items

Information contain in documents within the item


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Computer adaptive testing Items chosen for student based on previous

response

The test is designed to decide if you pass or fail

and will continue to test you until it is certain Items delivered one at a time

Test item must be answered or you cannot goto next item


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75 items given one at a time Computer then judges students performance

More items given in areas of poor performance

265 is most questions that it will offer

Time maximum is 5 hours


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I am going to present a test item,

give you a minute to answer

and then discuss the item

and content related to it.


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A. Explain the actual changes that will occur in her

body and then have her sign the consent formB. Delay having the patient sign surgical consent

and ask the surgeon to see her again

C. Allow the patient to sign consent for surgery;

she understands the surgery correctlyD. Tell the surgical staff to inform the surgeon

that the patient may need further informationduring recovery


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Total Hysterectomy is removal of the uterusand ovaries. Menstruation will stop and

menopause will start suddenlywhich itappears that she does not understand

The nurses role is not to explain theoperation, except for minor issues

The nurses signature indicates that thepatient (and not someone else) signed theconsent


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A legal document that provides evidence that thepatient has been given the reason for surgery,the other options (other operations, effect of notoperating, medications instead of surgery) andcomplications of surgery

This discussion must be done by the surgeon

Nurse witnesses the signature

Patient must be awake and not medicated

If the patient needs an operation for which he didnot consent, they have to be awaken foranesthesia and consent to a new procedure Many consent forms indicate options for different

procedures


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A. Higher than the IV dose

B. Lower than the IV dose

C.

The same as the IV dose


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Oral medications have a first pass effectthrough the liver. The liver excretes or bindsa large portion of the medication, makingless available to the patient. Therefore the

dose of oral meds is higher than IV meds.


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To achieve the same level of pain control, 10mg of Morphine IV is equal to: 30 mg of oral morphine

1200 mg of oral codeine

60 mg of oxymorphone


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A. Monitoring hyperalimentation (TPN) infusion

B. Dressing change on a wound the RN sawyesterday

C. Inserting an NG tube and administeringtube feeding

D. Teaching a newly diagnosed diabetic about

insulin injections


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LPN/LVNs cannot: insert NG tubes, they can monitor tube feeding

monitor IV fluids or meds

Teach complex material


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Delegating is assigning a task to another person,while the RN remains accountable

LPN/LVN A 1 year program of study in practical nursing

Very skilled at tasks and procedures Can learn complex assessments on the job

LPN/LVN cannot Insert NG or IVs Administer IV medications

Administer blood Develop care plans


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A. Stage IB. Stage IIC. Stage III

D. Stage IV


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Partial thickness ulcers Full thickness ulcers

Stage I

Stage IIStage IV

Stage III


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Prevention is key Intervene based on risk areas

Use Braden scale to help

Keep skin clean and dry

Turn patient side to side q 2 hrs Often delegated, consider how you will keep track of

patient position

Treatment

Nutrition Wound care

Sleep surface


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A. Pain level now 12/10;screaming

B. Pain level 6/10

C. Pain not present now,but going to PT in 1hour

D. Pain 2/10; keepingpatient from sleeping

E. Pain constant at 8/10

1. Acetaminophen 600 mgpo (Tylenol)

2. Morphine 2 mg IV3. Oxycodone 5 mg with

acetaminophen 500 mgpo4. OxyContin 10 mg po5. Acetaminophen (500

mg) and propoxyphene(50 mg) (Darvocet)

6. Fentanyl 100mg patch


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A. Pain level now 12/10;screaming = 2

B. Pain level 6/10 = 3 or 5

C. Pain not present now,

but going to PT in 1hour = 3 or 5

D. Pain 2/10; keepingpatient from sleeping= 1

E. Pain constant at 8/10= 2 and then 4 or 6

1. Acetaminophen 600 mgpo (Tylenol)

2. Morphine 2 mg IV3. Oxycodone 5 mg with

acetaminophen 500 mgpo4. OxyContin 10 mg po5. Acetaminophen (500

mg) and propoxyphene(50 mg) (Darvocet)

6. Fentanyl 100 mg patch


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Examine degree of pain Examine tolerance of pain

Consider effect of last dose of analgesic

Consider side effects and adverse effects ofdrug


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Ideal for intense pain Best given IV when pain is high

Onset is rapid

Side effects Constipation Tolerance

Adverse Effects Respiratory Depression

Oxygen saturation monitor used Do not turn off alarms!

But measure rate and depth ofrespirations


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Slow release oxycodone Ideal for cancer patients in

escalating pain

High risk of addiction

Do Not Crush these pills Leads to overdose

Do not confuse with Oxytocin


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Indicated for moderate Onset 30-45 minutes

Side effects the same

Adverse effect Hepatotoxicity from acetaminophen over 4000mg

in 24 hours


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A. Elderly ageB. Use of diuretics

C. Use of sedatives

D. Prior fall

E. WeaknessF. Sensory loss

G. Confusion


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Multiple options is a common format in theNCLEX and no partial credit is given for

correct answers


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A. Carefully lift the patient back to bed

B. Ask the patient why he got out of bed

C. Call the physician to examine the patient

D. Leave the patient on the floor and examinehim for signs of fracture


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Moving the patient could further harm afractured limb. Once the probably injury isknown, he may best be moved onto a cart forxrays

Calling the MD will be done, but not first, firstcollect some data

Asking the patient why he got up will provide

data to prevent future falls, but does not helpthis problem


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Most common reason is to use the bathroom High risk patients

Elders, frequent voiding (diuretics), confused


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A. Sharp pain in the hip

B. Internal rotation of the leg

C. Shortening of the leg

D. Bleeding from the hip


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This patient appears tohave a broken left hip.

Fractured bones lead tospasm of the limb Shortens the limb

Deforms the limb

External rotation in the leg

Pain in the limb

Loss of function

Loss of motion

Bleeding is due to tissueinjury, not fracture per se


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A. I will use a chair with arms

B. I will cross my legs gentlyC. I will only lie on my right side

D. I will avoid climbing stairs


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Flexion of the hip, internal rotation andabduction are to be avoiding

Therefore: She cannot cross her legs

She cannot lie on her sides without a pillow toabduct the leg

She must use a chair with arms to avoid hip flexion

Climbing the stairs is OK


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Flexion and extension Abduction and adduction

Internal and external rotation


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A. Maintain NPO status

B. Remove all metal objectsC. Obtain a consent for the procedure

D. Clarify allergies to contrast or shell fish


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Contrast dye, which can contain iodine, isoften used to visualize the vessels

The patient does not need to be NPO

Metal is not a problem with CT, it is aproblem with MRI

CT is noninvasive; no consent is needed


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Magnetic Resonance provides much greater contrast

between soft tissues Magnetic rays align atoms Prep

Sedation prn if claustrophobic

No metal due to magnet

Ear plugs prn due to noise

Computerized (Axial)Tomography scan. T series of cross sectional X-rays computer to put them together

to provide an image Prep

Very rapid, so sedation not used Metal OK

CT scanner requires patient

be still. Claustrophobia maybe a concern with somepatients


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A. An obese middle-aged woman at bedrestafter pelvic surgery

B. An elderly man with a fractured arm uptwice daily

C. A normal weight middle-aged man whosmokes

D. An demented elderly woman with afractured hip; up to the chair


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Her risk factors are immobility, pelvic surgeryand obesity

Moving patients are at less risk

Smoking is a risk factor, but needs to becombined with other risk factors

Fractured hips and elders are at risk,especially when bedridden


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Risk Factors Presentation

Risk factors Sluggish blood movement

Swelling in the pelvis,nonmoving legs

Increased blood clottingtendency Increased platelet count

Injury to vessels in pelvisor legs

Fractures of the hips,pelvis

Presentation Dyspnea

Anxiety

Tachycardia Tachypnea

Decreased O2 sats


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A. It should dissolve it in 4 to 6 hours

B. Because you have taken a lot of vitamin K, itmay be a day or two

C. It will not dissolve the clot, it will prevent newones from forming

D. It will only soften the clot, which makes it easierfor your body to break it down


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Antithrombotics work in 4-6 hours Used in some clients after stroke and MI

Vitamin K does not affect Heparin, vitamin K

affects warfarin It reduces the effectiveness of warfarin

Is used to reverse warfarin

It does not soften the clot, but the body does

breakdown the clot


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Heparin (heparin sodium) Half life 4 hours Reversible with Monitor partial thromboplastin times Given IV or subq

Low molecular weight heparins Given once daily, subq Cannot be monitored by blood studies

Coumadin (warfarin) Given orally Monitor INR (therapeutic 2-3) and prothrombin time (PT)

Can be taken for years Animal heart valves, venous disease

Reversed with vitamin K (Aqua-Mephtyon) Affected by foods with vitamin K


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A. PT

B. INR

C. PTTD. Bleeding Time


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Heparin is monitored by PTT Usually drawn every 4-8 hours

PT (prothrombin time)

Used to monitor Coumadin INR (International Normalized Ratio)

Used to monitor Coumadin Standardized international measure

Allows patients to travel

Bleeding time Used for unusual bleeding diseases


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A. At 12 ml per hour

B. At 25 ml per hour

C. At 50 ml per hour

D. At 250 ml per hour


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250 ml/25,000 units = 100 units/1 ml 250/25000 = 1/100

Therefore 12 ml delivers 1200 units per hour

This is a very common error in medication

delivery and will be tested!!


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A. The son cannot speak English well

B. The sons breath smells of alcohol

C. The son states his mother does not have

insuranceD. The son is talking on his cell phone while

listening to the discharge plan


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The patient may have an occult (not nowvisible) head injury: Decreasing level of consciousness Pain Vomiting

Pupillary changes Loss of motion or strength in limbs

Being alert is important to recognize thesechanges

The nurse needs to ask him to put the cell

phone down and listen Interpreters can be used to provide information Insurance does not change the standard of care


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Advocacy for patients is a very importantnursing role Especially for those patients who cannot advocate

for themselves Demented, sedated, children, unconscious

Advocacy can mean Asking MDs for information or orders Clarifying orders and information provided to the

patient

Determining the disposition of the patient Who will provide care for patient? Are they competent

to do so?


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1. Patient who needs insulin prior to eatingbreakfast, 0600 blood glucose was 122.

2. Patient who is being dismissed to home todayand needs discharge medication instruction.

3. Patient who has been receiving first unit ofblood since 0400; second unit is needed.

4. Patient who is going to surgery later thismorning and needs consent form signed.

5. Patient who had surgery yesterday and took lastprn oral pain med at 0500.


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3, patient getting blood 5, patient who may been in pain

1, patient who needs insulin

4, patient going to surgery

2, patient going home


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ABCs helpful Patient with these issues seen first Patients at risk for these problems seen first Or patients who might die of the problem if not

seen first

Treatments with time limits Blood cannot infuse over 4 hours

Actual problems over potential problems Except with head injury

Teaching considered low priority in mostcases


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A. Suctioning a tracheostomyB. Turning a patient side to sideC. Calculating intake and outputD. Administering an oral medicationE. Feeding a patient who has had a new stroke

and is at risk of aspirationF. Collecting vital signs on a stable patient

who has had surgery


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Suctioning airways requires sterile technique

Administering oral medications requires alicense

Feeding patients at risk of aspiration requiresassessment skill


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Nurses aides with 6 weeks of training Persons with on the job training Assign them tasks based on:

Task is repetitive and requires little supervision Relatively noninvasive

Assign them to patients who are Medically stable; they do not have assessment

skills beyond what they have learned on their own

Give them specific instructions on what to

report back to you and when


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A. Activate the fire alarm by calling the operatorB. Cover the wound and remove the patient from

the room

C. Place a pillow or blanket over the TV to put the

fire outD. Leave the leg undressed and remove the patient

from the room


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A. The patient is the priority, not infection

controlB. If the fire was small, in a waste basket for

example, it might be able to be contained,but a TV is an electrical


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RACE is the most common acronym Rescue the patient

Activate the Alarms

Contain the Fire

Close the doors

Close the fire doors

Extinguish the Fire


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A. Draw a sample of blood just before the nextdose and at the end of the infusion

B. Draw a sample of blood just before the nextdose and 1 hour after the infusion in complete

C. Obtain a sample of urine just before the nextdose and at the end of the infusion

D. Obtain a sample of urine just before the nextdose and 1 hour after the infusion in complete


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Peak concentrations of medications occur

when the medicine is at its highest level For IV meds, this is when the medication has

completely infuses

For oral medications, it is about 30-45 minutes

after ingestion Trough (low) concentrations occur just before

the next dose


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Medications that have a toxic effect on theliver, kidneys or ears need to be monitored

Patients with liver or kidney disease cannotexcrete the meds and become toxic more

rapidly Therefore doses can be reduced or frequency be

made longer (eg, every 18 hours, every other day)


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A. I drink grapefruit juice every morning.

B. I eat a lot of spinach and kale.

C. I drink milk with every meal.

D. I have changed to K Salt.


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Dark green vegetablescontain vitamin K

Spinach and kalecontain large amountsof vitamin K. Vitamin Kinterferes with theeffect of warfarin andshould not be eaten.


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Foods may alter absorption or bind with themedication Common problems:

Grapefruit juiceis metabolized by the same enzyme thatmetabolizes medications Antibiotics, Antihypertensives (calcium channel blockers),

Antiarrhythmics, Hormone Replacements, Cholesterol Blockers Tyramine with MAOs for psychiatric disease leads to

hypertensive crisis Tyramine found in beer, red wine, cheese, processed meats,

fruit, chocolate and nuts Milk or food and antibiotics

Delay absorption Potassium salt is substituted for NaCl

Very bitter and Much more salty Use with caution with kidney failure


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A. Hold the drug and notify the pharmacistB. Substitute a cephalosporin of equal strength

C. Explain that IV allergies do not cross over tooral allergies

D. Ask the patient to describe what happenedlast time she took Penicillin


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Some patients will report being allergicwhen they are not. They believe that havingan upset stomach is an allergy

The pharmacist will not be able to change the

order Allergies are not route dependent

The nurse cannot independently change the

drug from what is ordered


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Hives of theface and neck Skin rash is common

Several types Mild localized rash

Systemic effects

Anaphylaxis

Airway and facial edema

Occur with a secondexposure Immune system is set to

trigger a second response


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A. The ability of the patient to swallowB. Previous allergies to this medication or

PenicillinC. What other medications the patient

routinely takesD. The ability of the patient to adhere to the

TID drug regimine


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Augmentin pills are large and strep throatmay prevent swallowing them

Augmentin contains Penicillin and a crossover allergy is possible

Other medications, such as birth control pills,may interaction

Adherence to a TID regimen may be difficult


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Patients can take 20 ormore pills in one day

NSAID Sulfa Macrolides

- mycin antibiotics Quinolones

ciprofloxacin, enoxacin,norfloxacin, and ofloxacin Phenytoin

Quinolones

ACE inhibitors Potassium replacements

Spironolactone

Digoxin Amiodarone

Verapamil


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A. Jaundice

B. Oliguria

C. CandidiasisD. Gastric Bleeding


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Candidiasis (vaginal is very common) occurswhen the bacterial flora are altered andCandida grows unchecked Presentation is vaginal itching and pain, and a white

cheese-like drainageJaundice, oliguria and gastric bleeding is not

due to antibiotic Buy if present should be reported to the MD


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Proliferation(growth) oforganisms not killedby the antibiotic

Vaginal - vaginitis Bowel -- diarrhea

Oral -- thrush

Prevention with

probiotics? Lactobacillus in yogurt

can restore balance


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A. Avoid alcoholB. Limit fluids to 1000 ml per day

C. Avoid exposure to the sunlight

D. Limit consumption of milk products


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All the sulfa drugs can lead tophotosensitivity

Alcohol is avoided with Flagyl (metronidazole)

Milk delays absorption, it does not interfere

with this drug actions


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A. An elderly woman who lives in a nursinghome

B. A middle aged woman who has just gotten ahead cold

C. A young nurse with an allergy to eggs

D. An elderly woman who had a reaction to theflu vaccine last year


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High risk patients for influenza are: The elderly The institutionalized Persons with respiratory disease Health care providers

Influenza vaccine is contraindicatedin:

Persons with febrile illness Persons with egg allergy Persons who have had a prior reaction


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Natural = Nonspecific immunity From intact skin and white blood cells

Acquired Immunity = Antibodies Active = have the disease

Active = have an immunization

Passive = borrow the antibodies from others ormother


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A. YesB. No

C. I have no idea!


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Thrombolytics are used to dissolve the clot Drug names end in ase

However they dissolve all clots Not used with bleeding strokes, other sources of

bleeding


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Left sided stroke Right sided weakness

Language, mathematical and analytic processesimpaired

Right sided stroke Left sided weakness

Visual and spatial loss and loss of proprioception

Awareness of body in space Neglect of left side of body


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A.

Daily oral care with flossing will be neededB. Take the medication each morning with milk

C. The medication should be used until he isseizure free for 1 year

D. Limit alcohol consumption to 2 glasses ofwine daily


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Phenytoin has a narrowtherapeutic range

Gingival hyperplasiafrom poor oral care

Phenytoin is notabsorbed with milk ortube feeding

It needs to be taken forlife

Alcohol reduces itsabsorption Increases risk of seizures


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Digoxin (digitalis)

Phenytoin (Dilantin)

Warfarin (Coumadin)

Gentamicin Phenobarbital

Quinine

Patients quicklybecome toxic

Blood levels are drawnwhen doses arechanged

Nurses need tomonitor for signs andsymptoms of toxicity


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A. Heart failure

B. Asthma

C. DiabetesD. Dementia


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Propranolol is a nonselective Alpha and Betablocker, therefore will causebronchoconstriction

It should be used cautiously in diabetics May mask hypoglycemia

It is used for the treatment of heart failure

It has no contraindications in dementia


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Alpha 1 receptors are in the arterioles When stimulated lead sympathetic response

Flight or fight

Peripheral vasoconstriction to shunt blood

Tachycardia

Beta 1 receptors When stimulated lead to increased heart rate and increased

myocardial contraction

Beta 2 receptors

When stimulated lead to vasodilation, bronchodilation, musclecontraction


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A. Potassium 2.3B. Potassium 5.5

C. Sodium 135

D. Sodium 145


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Furosemide is a potassium wasting diuretic Loop diuretic

Normal values of potassium are 3 or 3.5 to 5or 5.5

Sodium range is 135-145 If this patients sodium is trending higher, MD

should be asked, patient may be becomingdehydrated


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You must memorize Sodium - 135-145

Potassium 3-5.5

Calcium 7-9

Dehydration can lead to false positives Values are higher than true numbers

Overhydration can lead to false negatives Dilutional effects


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A. Calcium 8.5

B. Chloride 100

C. Potassium 3.0

D. Sodium 122


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Sodium is the majorextracellular ion

When patient is dehydrated Fluid is lost

Sodium is not The portion of sodium is larger

More concentrated


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A. Chew on hard candy for dry mouthB. Take the medication on an empty stomach

C. Increase the amount of calcium taken daily

D. Increase the amount of fluid and fiber takendaily


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Calcium channel blockers increaseconstipation Smooth muscle in the colon does not work as well

They do not need to be taken on an empty

stomach They do not lead to dry mouth

They do not require that calcium intake bechanged


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End in the suffix pril inhibit depolarization-

induced Ca2+ entry intosmooth and cardiac

muscle cells in thecardiovascular system Smooth muscle in

arterioles where BP is

controlled


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A. 1 liter per minuteB. 2 liters per minute

C. 3 liters per minute

D. 4 liters per minute


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Oxygen therapy is provided in % by facemasks Each 4 percent = I liter by nasal cannula

Room air is 20%, so

24% = 1 liter 28% = 2 liters

32% = 3 liters

36% = 4 liters

Maximum oxygen by NC is 6 liters

At this rate, it dries the nasal mucosa and leads tobleeding


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Titrated to oxygen saturation in blood Measured by probe on finger or ear

Normal % is over 92%

Use lowest level of oxygen to meet O2 needs

Use of oxygen in patients with emphysema Drive to breath is hypoxia (not hypercapnia)

So if oxygen given, drive to breathe can be suppressed

Usually given only1-2 liters of oxygen

Venturi masks can deliver oxygen at specificpercentage


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A. Less coughing

B. O2 sats > 95%

C. Respiratory rate of 28/bpm

D. Fewer crackles in the chest


103/189

The purpose of suctioning is to removesecretions from the tube and upper airways Suction catheters do not reach alveoli

Lung sounds will not improve until the patient

coughs Suctioning will cause reflex coughing

Respiratory rate should decrease


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A. I will stop using the inhaler if I get handtremors after using it.

B. I should use the inhaler as a rescue drug ifmy chest feels tight.

C. I should stop using the inhaler when I amtaking steroids.

D. I will take this inhaler daily to keep myasthma in control.


105/189

Albuterol is an inhaled bronchodilator usedfor acute care of bronchospasm.

It can lead to tachycardia and tremorsbecause it is an alpha 1 agonist.

It is often used in combination with steroidsfor the treatment of acute asthma.

It is not a daily drug or a routine drug;inhaled steroids are used for this purpose.


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Asthma presentationPeak flow is key tomonitoring

Allergic response Inflammation

Airway swells and spasmsclosed

Presentation

Wheezing Dyspnea

Decreased peak flow

Measured by patient


107/189

A. Presence of gag reflex

B. Color and amount of sputum

C. Ability to turn head side to side

D. Chest pain that worsens with inspiration


108/189

The airway is numbed for the procedure Gag reflex is blocked for up to 2 hours

Do not feed the patient until gag reflex returns

Aspiration could develop

Assessment of sputum is not unique in thiscase

Injury to the neck from hyperextension couldoccur, but rare

Pneumothorax could occur, but rare and notunique to this procedure


109/189

Examination of the bronchiwith a lighted tube Remove mucus

Biopsy airway tumors/masses

Remove foreign objects Patient is sedated

Airway is numbed


110/189

A. Blood in the

collectionchamber

B. Air bubbling inthe air seal

C. Air bubbling inthe suctioncontrol chamber


111/189

A. Blood in thecollection chamber

A. From thehemothorax

B. Air bubbling in theair seal

A. From thepneumothorax

C. Air bubbling inthe

suction controlchamber

A. From the wall suction

Fluid collection

Water seal

Suctioncontrol


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Placed into the pleural space Upper chest to remove air Lower chest to remove fluid

If system opens Air reenters pleural space and lung can collapse


113/189

A. Ondansetron (Zofran)

B. Metoclopramide (Reglan)C. Prochlorperazine (Compazine)

D. Dimenhydrinate (Dramamine)


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Ondansetron (Zofran) works on the vomitingcenter in the brain

Metoclopramide (Reglan) is a GI stimulant andbest used for nausea after surgery

Prochlorperazine (Compazine) can lead toextrapyramidal effects Tremor, restlessness, uncontrollable speech

Dimenhydrinate (Dramamine) Commonly used for motion sickness


115/189

Chemoreceptor trigger zone area of the brain which receives inputs from blood-

born drugs or hormones, and communicates withthe nearby vomiting center to initiate vomiting

Treat nausea prior to chemotherapy Treat nausea prior to surgery


116/189

A. Let the patient take the medsB. Review the Medication Administration

Record and let her take the important onesC. Do not let her take the medications, report

the error and notify the MD

D. Do not let her take the medications andnotify the charge nurse


117/189

The patient cannot take the meds, too muchtime has past and the nurse may have thesame meds for 0900

The MD may need to change the prescription

to replace the missing medications;something that the charge nurse cannot do


118/189

Right drug Know how to correctly

compute dose

Check your work 3 times

Right dose Know algebra and how to

compute doses based onbody weight

Right patient Check ID band Have patient state his/her

name

Right time Know schedule for QD,

BID, TID, Q 6 hrs, beforeand after meals

Right route Know incompatibilities

with IV meds Know drug-drug, drug-

food interactions Right documentation

Chart only after the med

is given


119/189

A. Discontinue the IV

B. Change the IV tubing

C. Slow the infusion rate

D. Apply a hot pack to the IV site


120/189

The IV has infiltrated and needs to bestopped. The fluid is infusing into the tissuesnot the vein.

IV tubing is changed every 48 to 72 hours

routinely Slowing the infusion rate will not stop the

infiltration

Hot packs can be applied after the IV catheter

is out to help with fluid reabsorption


121/189

IVs are often started by RNs

3 attempts is the usual maximumnumber of triesUsually started first in the handThen future sites are movedproximal in the arm

IV site complicationsInfiltration needle has

slipped and fluid is going into

tissuesExtravasation toxic meds

going into tissues


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A. Dyspnea

B. Polyuria

C. Confusion

D. IV site infiltration


123/189

The IV fluid may have been deposited in hislungs when in fluid overload.

Polyuria would be great, it would mean thathis kidneys are excreting the fluids.

Confusion may be a concern, it may indicatehe has developed cerebral edema.

IV site infiltration would be worrisome, if thefluid is now in his arm, but not the most

severe problem.


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Sterile fluids infused into thebody through a catheter in a vein

Used to replace fluids in thevascular space (vessels)

Types of fluids Isotonic saline, D5W, LR

Hypertonic combinations of NS andglucose and Lactated Ringers

Hypotonic less than NS (.2, .45 NS

without glucose) Prescribed at hourly rates

Adult rates range from 75-125 ml/hr


125/189

A. Remove the catheter and attempt to reinsertit into the urethra

B. Leave the catheter in the vagina and attemptto insert a new catheter into the urethra

C. Ask the patient to use the bedpan so thatthe urethra is open

D. Examine the perineum more closely andattempt to identify the urethra


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Common problems includeimproper exposure and poorlightening

Do not reuse the samecatheter

Leaving the old catheter in thevagina is not a bad idea; itprovides a marker

Using the bedpan will not

open the urethra long enoughfor you to see it


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Sterile items only remain sterile if they touchother sterile items

A sterile field is not sterile if you turn yourback to it

Exposure the perineum with yournondominant hand; so that your gloved handremains sterile


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A. I bought a good moisturizer for my feet.

B. I will use a mirror to check my feet every

night.C. I have found a place to buy shoes that have

a broad toe space.

D. I will use a hot baths every night to

increase blood flow to my feet.


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Diabetics develop neuropathy and cannot feelpain. Therefore hot water could burn thepatient.

Keeping the skin moist prevents fissures andcracks

Broad toe in a shoe is idea

Examining the skin on the feet with a mirroris critical for finding skin problems early


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After 10 years of diabetes, especiallyif poorly controlled blood glucose Retinopathy

Loss of vision Nephropathy

Loss of kidney function

May need dialysis Neuropathy

Dense numbness of the legs Easily injured Very slow to heal open wounds May lead to amputation

Autonomic neuropathy Slowed digestion Blood pressure problems (low or high)


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A. Consent to be Treated

B. Advance Directives

C. Patients Bill of Rights (Patient Partnerships)

D. Consent for Surgery


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Tumor? Impaction?

Hematoma?

Abdominal aortic aneurysm?


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Cues: pulsatile, sudden onset Likely treatment: either surgery or allow it to

rupture without treatment to end her life

Surgery

Likelihood of living is low So, confirming Advanced Directives is very

important


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Living Will The patients desires for treatments that prolong

life

DNR, tube feeding, intubation, CPR, cardiac meds

Durable Power of Attorney A person who can make decisions about life, death,

treatments on behalf of the patient


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A. Plan to do CPR if his heart stops

B. Contact the physician now for an updatedDNR order

C. Place a note on the chart for the physicianto renew the DNR

D. Ask the patient what he wants done if hisheart stops today and do what he wants


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Patients condition is deteriorating and hemay die soon

No assumptions can be made about preferredDNR status

Patient has to be in right mind or sane tomake this decision You could ask and give this information to the MD

Morphine clouds judgement

Once CPR starts, even if on a DNR patient bymistake, it must continue


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Orders written by MD after discussion withpatient or family

In some states, a DNR expires after 6 months Assuming the patients condition may have

improved

If no DNR is present on the record, all

resusitation takes place


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A. Allow him to leave as he intendsB. Validate that he understands the possible

consequences of his decision

C. Have him sign a leaving against medical advice

document before leavingD. Ask security to detain him until someone can sign

consent to be treated for him


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Angina can be due to occlusion of thecoronary arteries

Angina can precede a fatal myocardial

infarction The MD has to be notified, but if the patient

is left alone he may leave as he intends

Security cannot retain him, this could be seenas false imprisonment


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All patients have the right to refuse care

They must know and be able to comprehend theconsequences of this decision Demented patients cannot refuse carethey cannot

understand the consequences

Documentation of the conversations must be verycomplete Law suits can occur if patient suffers the consequences

and it is not clear that he was fully informed

Leaving against medical advice (AMA) Legal document that protects hospital from law suits If patient is at risk of harm to self or others may need to

be commitment to a mental health facility


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A. Ambulate upon return from the study

B. Assess puncture site for hematomaC. Avoid antiplatelet medications

D. Restrict oral and IV fluids


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The femoral artery is often the access siteand can quickly develop hematoma or bleed

The patient will be at bedrest with a pressuredevice on the groin (sandbag, pressure

gauge) Antiplatelet meds (Clopidogrel [Plavix],

aspirin, low molecular weight heparin) aregiven

Oral of IV fluids are pushed to remove thecontrast and prevent kidney injury


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Dye study of thecoronary arteries Invasive need consent

Dye check allergies toiodine or shellfish

Indications Chest pain

Unstable angina with STsegment changes

Confirmation of theextent of heart disease


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A. The exact location of the pain

B. If the pain radiates and to where

C. What makes the pain better and worseD. Does taking a deep breath cause pain

E. Vital signs and oxygen saturation

F. Color of the skin, diaphoresis


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Angina and MI

Pulmonary Embolus Some pain, more

tachycardia, tachypnea,decreased O2 sats, anxiety

Pleurisy Pain is worse with

breathing and sharp

Gastric distress/ulcers Pain related to diet

Pain better with food


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A. Medicate him for pain and splint the chestB. Suction his airway to remove the secretions

C. Increase his FIO2 to reduce his need tocough

D. Increase his fluid intake to thin thesecretions


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Incisional pain is made worse with coughing,so analgesics will help

His oxygen needs to be kept over 93-95% but

it is not to reduce the need to cough Suctioning him would be traumatic and would

make him violently cough

Fluids are often restricted after heart surgeryto avoid fluid overload


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Priorities of care Rhythm management

Edema and trauma tofibers

BP management

Hypotension may causegrafts to collapse

Hypertension maycause bleeding fromgrafts

Chest care Congestion common

Pain management


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A. Nothing

B. Administer sublingual nitroglycerin

C. Call a cardiac arrest, and begin CPR

D. Determine if the patient is conscious, if

not proceed with CPR


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A. Nothing, continue to monitor



D. Determine if the patient is conscious, ifnot proceed with CPR


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A. Nothing



D. Determine if the patient is conscious, if

not proceed with CPR


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A. Nothing



D. Determine if the patient is conscious, ifnot proceed with CPR


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V fibrillation

V tachy (cardia)

Asystole


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A. I will take my water pill (furosemide) atnight.

B. I will take my heart rhythm pill (digoxin)when my pulse gets to 60.

C. I will have my blood (warfarin) tested weeklywhile I take this blood thinner.

D. I only need to take this blood pressure pill(Captopril) weekly.


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PT and INR is monitored weekly

at first to make dose changes Impacted by vitamin K intake

Furosemide is taken in the AM

Digoxin reduces heart rate

Pulse needs to be taken for aminute

Toxicity includes seeing yellowrings, fatigue, weakness, confusionand anorexia

BP meds are taken daily BP should be monitored


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A. Push 40 mEq of KCl into a central lineB. Push 20 mEq of KCl into a peripheral line

C. Infuse diluted KCl at 20 mEq per hourthrough a peripheral line

D. Infuse diluted KCl at 20 mEq per hourthrough a central line


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Never, never, ever give undiluted potassium

It stops the heart and the heart cannot befixed!

Diluted potassium is given

10 mEq through a peripheral line 20 mEq through a central line


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Peripheral lines are inthe arms and hands

Central lines are placed byMDs into subclavian andother large vessels


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A. Cred maneuvers

B. Kegel exercisesC. Increased calcium intake

D. Limit oral intake of fluids


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Kegel exercises strengthen the pelvic floor

Cred maneuvers is tapping over the bladder used by spinal cord injured to relax the bladder

Calcium has no impact

Oral fluids should not be restricted Other suggestions

Limit alcohol and caffeine

Used prescribed hormone therapy


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Stress Occurs with laughing, jumping, coughing

Mainly in women, follow child birth

Urge Seen with urinary infections

Functional Cannot reach the toilet in time or cannot remove

clothing in time

Total Unaware of need to void


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A. Furosemide 20 mg IV statB. IV NS 1000 ml bolus over 1 hour

C. Irrigate the catheter with 30 ml NS

D.

Continue to monitor for another hour


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The patient is dehydrated, he needs fluidsand quickly to prevent renal failure

Furosemide will create urine, but worsendehydration

The catheter does not appear to be plugged Plugged catheters produce no urine

Monitoring for another hour does not fix theproblem


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Prerenal renal failure Lack of blood getting to the kidneys

Seen in hemorrhage, edema (burns), dehydration

Treated with fluids

Intrarenal renal failure Diseases of the kidney Seen with nephrotic syndrome, diabetes, infection, meds

Treatment of the disease

Postrenal renal failure

Obstruction to flow past the kidneys Seen with prostate disease, kinked of plugged catheters

Treatment is remove the obstruction


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A. Give him 1-2 units of Lispro SQ

B. Notify the dietician to deliver his food traynow

C. Recheck his blood glucose first then givehim 15 g of glucose

D. Give him 15 g of glucose and recheck hisblood glucose in 15 minutes


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Normal blood glucose is 70-100 (110)

Hypoglycemia is serious and needs immediatetreatment

Lispro is rapid acting insulin---would make theproblem worse

There is no point in rechecking the reading; he islethargic, it is probably right Little error in treating

Getting his tray of food wont help; he cant eat it


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Hypoglycemia Below 70, treat with 15 g of glucose

Below 60, start with 15g and recheck glucose

Below 50, add a long acting sugar (eg crackers)

Below 40, use glucagonpatient usually

nonresponsive

Hyperglycemia Treat with short acting insulin, called sliding scale

Based on blood glucose reading

Replace fluids lost with diuresis


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A. None, this is a normal finding

B. Irrigate the ileostomy

C. Increase the patients activity

D. Notify the surgeon of the bowel obstruction


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Ileostomy does not have output for about 3days after surgery. The initial output is mucus

Irrigation would be contraindicated The suture sites are too new

The output is fluid

Activity could be increased for other reasons,but it would not change bowel output

There is no obstruction present


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Resection of bowelResidual stoma produces the type

of stool based on where it was priorto surgery

Stoma should be pink and abovethe skin level, so that appliancecan be attached


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A. Brownies with ice creamB. Pasta with marinara sauce

C. Strawberries with sugar

D. Poached eggs on toast


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High fat foods with stimulate the gall bladderto contract leading to pain

All the foods with sugar or starch or proteinare fine

Pain from gallbladder disease presents as Shoulder blade pain after eating fatty diet

Nausea, belching


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Cholecystectomy (not colostomy)

Done with scope Laparoscopic cholecystectomy

Smaller incision

Shorter hospital stay

Pain from air used in case

Diet afterwards can include

Fats

Bile is released continuosly


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A. Vomiting and abdominal pain

B. BP 122/83 lying and 92/66 standingC. Bluish discoloration around the umbilicus

D. Serum amylase 4 times higher than normal


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This patient is dehydrated and needs IV fluids

Periumbilical blueness (called Cullens sign),elevated amylase, pain and vomiting areexpected findings


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Serum enzymes are elevated whenever cellsare destroyed Amylase and lipase normally in the pancreas are

elevated with pancreatitis

Creatinine kinase and troponin elevated with

myocardial injury Creatinine kinase also elevated with muscle injury

Nurses expected to know which lab values arechanged in various diseases and notify MDs

when abnormal and unexpected findings arepresent


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A. Long acting insulin is used

B. Blood glucose is checked dailyC. MD orders are needed for TPN daily

D. Clean technique is used when changing TPNtubing or bags

l b d d l


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Hyperalimentation is prescribed daily Bags are hung to last 24 hours

If delivery falls behind or is ahead of schedule, it isnot made up

Blood glucose is checked 4 times a day and

treated with sliding scale regular insulin

Sterile technique is used with TPN Given through central lines

d f fl d d l


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Administration of fluids, protein and caloriesthrough a vein. Fats are also commonly givenin a separate infusion

Indications unable to absorb nutrients through the intestinal

tract

severe vomiting, diarrhea, or intestinal disease

Also called parenteral nutrition, totalparenteral nutrition, and TPN.


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C t t k l d f


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Content you know now was learned for a

specific test Create a study plan for review

You need to be able to recall informationpresented randomly Study information in sets to see relationships

E.g., heart disease

Make yourself recall it randomly Make cards to test yourself at odd times

Meet with friends to quiz each other on random topics

Mix up the material Add priority setting to heart disease, add it to OB, etc


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Eli i b i


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Eliminate obvious wrong answers

This exam does not have obvious errors Answer C is not always right

Longest answer is not always right

OK to guess if you have a sense it is right Do not run through the exam at the end and

guess on all unanswered items

S l t t


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Sample test www.4tests.com/exams

www.nclextestnaswers.com

Daily test items online Google to find sites
http://www.4tests.com/examshttp://www.4tests.com/exams


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